ATI Detailed Answer Key Medical Surgical

Questions 29

ATI RN

ATI RN Test Bank

ATI Detailed Answer Key Medical Surgical Questions

Question 1 of 5

A client with a chest tube connected to a closed drainage system needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: When transporting a client with a chest tube connected to a closed drainage system, it is crucial to keep the drainage system below the level of the client's chest at all times. This positioning prevents the backflow of drainage into the client's chest, reducing the risk of complications. Clamping the chest tube, disconnecting it from the drainage system, or emptying the collection chamber are incorrect actions and can potentially harm the client or lead to complications.

Question 2 of 5

A client with emphysema is being cared for by a nurse. Which of the following findings should the nurse not expect to assess in this client?

Correct Answer: B

Rationale: Emphysema is a chronic lung condition characterized by shortness of breath (dyspnea), a barrel-shaped chest due to hyperinflation of the lungs (barrel chest), and clubbing of the fingers (enlargement of fingertips). Bradycardia (slow heart rate) is not typically associated with emphysema. In emphysema, the primary focus is on respiratory complications rather than cardiac issues.

Question 3 of 5

A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?

Correct Answer: A

Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.

Question 4 of 5

A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Correct Answer: C

Rationale: Encouraging the use of an incentive spirometer is vital in preventing pulmonary complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, promoting lung expansion, and preventing atelectasis. Range-of-motion exercises help prevent musculoskeletal complications, while placing suction equipment at the bedside is important but not directly related to preventing pulmonary complications. Administering an expectorant may help with clearing secretions but is not as effective in preventing postoperative pulmonary complications as using an incentive spirometer.

Question 5 of 5

A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Correct Answer: B

Rationale: In myasthenia gravis, a neuromuscular disorder characterized by muscle weakness and fatigue, weakness is a common manifestation due to the immune system attacking the communication between nerves and muscles. Monitoring for weakness is crucial to assess the disease progression and determine the effectiveness of treatment. Confusion is not a typical manifestation of myasthenia gravis. Increased intracranial pressure and increased urinary output are not directly associated with this condition.

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