ATI RN
ATI Medical Surgical Proctored Exam 2023
1. A client is wearing a Venturi mask to receive oxygen, and the dinner tray has arrived. What action by the nurse is best?
- A. Assess the client's oxygen saturation and, if normal, turn off the oxygen.
- B. Determine if the client can switch to a nasal cannula during the meal.
- C. Have the client lift the mask off the face when taking bites of food.
- D. Turn off the oxygen while the client eats the meal and then restart it.
Correct answer: B
Rationale: In this scenario, the nurse should determine if the client can safely switch to a nasal cannula during meals. It is crucial to ensure that the provider has approved this change. Oxygen is considered a medication and should be delivered continuously. Turning off the oxygen or lifting the mask while eating can lead to a decrease in the FiO2 delivered, potentially compromising the client's oxygenation status. Therefore, the best course of action is to ascertain if transitioning to a nasal cannula is appropriate for the client during the meal.
2. A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?
- A. Holding the device securely when changing ties
- B. Suctioning the client first if secretions are present
- C. Tying a square knot at the back of the neck
- D. Using half-strength peroxide for cleansing
Correct answer: C
Rationale: When providing tracheostomy care, it is important to ensure the client's safety and prevent pressure ulcers. When securing ties that require knotting, the knot should be placed at the side of the client's neck, not at the back. Tying a square knot at the back of the neck could lead to discomfort, pressure ulcers, or accidental tightening. Holding the device securely, suctioning the client as needed, and using appropriate cleansing solutions are all essential components of tracheostomy care.
3. A healthcare professional assesses a client who is experiencing an acute asthma attack. Which assessment finding requires immediate intervention?
- A. Loud wheezing
- B. Increased respiratory rate
- C. Use of accessory muscles
- D. Silent chest
Correct answer: D
Rationale: A silent chest in a client experiencing an acute asthma attack indicates severe airway obstruction and impending respiratory failure. It is a critical finding that requires immediate intervention as it signifies a lack of airflow and ventilation. Loud wheezing, increased respiratory rate, and use of accessory muscles are common signs of an asthma attack and indicate the body's attempt to compensate. However, a silent chest suggests a dangerous lack of airflow that necessitates urgent medical attention to prevent respiratory arrest.
4. A client with a mediastinal chest tube is being assessed by a nurse. Which symptoms require the nurse's immediate intervention? (SATA)
- A. Production of pink sputum
- B. Tracheal deviation
- C. Pain at insertion site
- D. Sudden onset of shortness of breath
Correct answer: B
Rationale: Immediate intervention is necessary when a client with a mediastinal chest tube exhibits tracheal deviation since it may indicate a tension pneumothorax. This condition requires prompt attention to prevent serious complications. While the production of pink sputum and pain at the insertion site should be monitored and reported, they do not typically require immediate intervention. Sudden onset of shortness of breath could indicate various issues related to the chest tube but is not as critical as tracheal deviation in this context.
5. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
- A. Apply water-soluble ointment to nares and lips.
- B. Periodically adjust the oxygen flow rate.
- C. Remove the tubing from the client's nose.
- D. Turn the client every 2 hours or as needed.
Correct answer: A
Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.
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