ATI RN
ATI Medical Surgical Proctored Exam 2023
1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 22 breaths per minute
- C. Client reports shortness of breath
- D. Client's respiratory rate decreases to 10 breaths per minute
Correct answer: D
Rationale: A decrease in the client's respiratory rate to 10 breaths per minute, while receiving oxygen therapy for COPD, is a concerning finding that may indicate carbon dioxide retention and respiratory depression. This situation requires immediate action to prevent further complications. An oxygen saturation of 90% is within an acceptable range for COPD patients on oxygen therapy. A respiratory rate of 22 breaths per minute and reports of shortness of breath are common in clients with COPD and may not necessitate immediate action unless accompanied by other concerning symptoms.
2. A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select ONE that does not apply)
- A. Production of pink sputum
- B. Tracheal deviation
- C. Pain at insertion site
- D. Sudden onset of shortness of breath
Correct answer: A
Rationale: In a client with a mediastinal chest tube, the presence of pink sputum does not necessarily require immediate intervention. However, tracheal deviation could indicate a tension pneumothorax, sudden shortness of breath could signal tube issues or pneumothorax, and drainage exceeding 70 mL/hr might suggest hemorrhage. Disconnection at the Y site could lead to air entering the tubing, necessitating prompt attention.
3. A client has an oxygen saturation of 88% on room air. Which action should the nurse take first?
- A. Initiate oxygen therapy at 2 liters per minute via nasal cannula.
- B. Place the client in a high-Fowler's position.
- C. Notify the healthcare provider.
- D. Document the finding in the client's medical record.
Correct answer: A
Rationale: The priority action for a client with an oxygen saturation of 88% on room air is to initiate oxygen therapy to improve oxygen saturation levels. Oxygen therapy is crucial to address hypoxemia promptly. Placing the client in a high-Fowler's position can also aid in oxygenation, but administering oxygen takes precedence. While notifying the healthcare provider is important, it is a secondary action after ensuring the client's immediate need for oxygen is met. Documenting the finding in the client's medical record is necessary for continuity of care but is not the primary intervention when addressing hypoxemia.
4. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply)
- A. I held the client's morning bronchodilator medication.
- B. The client is ready to go down to radiology for this examination.
- C. Physical therapy states the client can run on a treadmill.
- D. I advised the client not to smoke for 6 hours prior to the test.
Correct answer: B
Rationale: Communication between the nurse and respiratory therapist is crucial before pulmonary function tests (PFTs). It is important to inform the respiratory therapist that the client is ready for the examination. The nurse should not administer bronchodilator medication before the test as it may affect the results, and the client should not smoke for 6 to 8 hours prior to the test to ensure accurate results. Additionally, PFTs do not involve running on a treadmill; instead, the client may be required to perform specific breathing maneuvers as instructed by the respiratory therapist.
5. The client is prescribed a long-acting beta2 agonist and expresses concerns about the cost, stating they only use the inhaler during asthma attacks. How should the nurse respond?
- A. Explain the importance of using the inhaler daily to prevent asthma attacks.
- B. Suggest identifying community services to help with the cost and encourage daily use of the inhaler.
- C. Explore the client's fears regarding breathlessness.
- D. Emphasize the necessity of using this inhaler daily and discuss potential community services for financial assistance.
Correct answer: B
Rationale: The correct response should address the client's concern about the cost of using the inhaler daily. While emphasizing the importance of daily use is crucial, it is also essential to acknowledge and offer support for the financial burden. Identifying community resources can help the client access affordable medications. Exploring fears related to breathlessness does not directly address the client's financial concerns.
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