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 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 2 of 5

The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?

Correct Answer: A

Rationale: Fluctuation of the fluid level within the water seal chamber indicates proper functioning of the chest tube. This fluctuation reflects the normal ebb and flow of air and fluid in the pleural space, demonstrating that the system is maintaining the appropriate pressure. Continuous bubbling in the water seal chamber may indicate an air leak, absence of fluid in the drainage tubing suggests a blockage, and equal amounts of fluid drainage in each collection chamber are not expected in this system.

Question 3 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 4 of 5

A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Correct Answer: C

Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.

Question 5 of 5

A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?

Correct Answer: D

Rationale: Following a total laryngectomy, maintaining a clear airway is crucial to prevent complications such as airway obstruction due to secretions or blood clots. Monitoring the need for suctioning takes precedence to ensure the client's airway remains patent. While monitoring pain levels, IV line patency, and dressing integrity are important aspects of care, ensuring adequate airway clearance through suctioning is the priority in this scenario.

Similar Questions

Join Our Community Today!

Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for ATI-RN and 3000+ practice questions to help you pass your ATI-RN exam.

Call to Action Image