ATI RN
ATI Detailed Answer Key Medical Surgical
1. A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?
- A. Confusion
- B. Weakness
- C. Increased intracranial pressure
- D. Increased urinary output
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.
2. A client with chronic obstructive pulmonary disease (COPD tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
- A. Maintaining a semi-Fowler's position as often as possible
- B. Administering oxygen via nasal cannula at 2 L/min
- C. Helping the client select a low-salt diet
- D. Encouraging the client to drink 2 to 3 L of water daily
Correct answer: D
Rationale: Encouraging the client to drink 2 to 3 liters of water daily helps to thin bronchial secretions, making them easier to expectorate. This can assist the client in coughing up the tenacious secretions. Maintaining a semi-Fowler's position can aid in improving lung expansion but may not directly address the issue of clearing the secretions. Administering oxygen via nasal cannula at 2 L/min can help improve oxygenation but does not specifically target the removal of bronchial secretions. Selecting a low-salt diet is important for overall health, but it does not directly address the client's immediate concern of clearing the bronchial secretions.
3. 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?
- A. Clamp the chest tube prior to transferring the client to a wheelchair.
- B. Disconnect the chest tube from the drainage system during transport.
- C. Keep the drainage system below the level of the client's chest at all times.
- D. Empty the collection chamber prior to transport.
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.
4. A client with a tracheostomy is being cared for by a nurse. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
- A. Attending a class on tracheostomy care
- B. Verbally explaining all steps in the procedure
- C. Performing the procedure independently
- D. Asking relevant questions about suctioning
Correct answer: C
Rationale: When the partner can independently perform the suctioning procedure, it demonstrates a readiness for the client's discharge. This indicates that the partner has acquired the necessary skills and knowledge to provide safe care for the client at home without the direct supervision of healthcare professionals.
5. During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?
- A. Dysphagia
- B. Hoarseness
- C. Dyspnea
- D. Weight loss
Correct answer: B
Rationale: In clients with laryngeal cancer, hoarseness is often one of the earliest manifestations due to vocal cord involvement. The irritation and inflammation caused by the tumor affect the vocal cords, leading to changes in voice quality. Dysphagia (choice A) typically occurs later as the tumor grows and interferes with swallowing. Dyspnea (choice C) and weight loss (choice D) may occur as the cancer progresses, but hoarseness is usually among the first signs to manifest in laryngeal cancer.
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