ATI RN
Medical Surgical ATI Proctored Exam
1. A client with COPD is developing a plan of care. Which of the following interventions should the nurse include in the plan?
- A. Restrict the client's fluid intake to less than 2 L/day
- B. Provide the client with a low-protein diet
- C. Have the client use the early-morning hours for exercise and activity
- D. Instruct the client to use pursed-lip breathing
Correct answer: D
Rationale: In COPD, pursed-lip breathing helps improve breathing efficiency by maintaining positive pressure in the airways, preventing airway collapse, and promoting oxygenation. This technique assists in controlling respiratory rate, reducing dyspnea, and enhancing oxygen saturation levels. Restricting fluid intake is not typically a part of COPD management. Providing a low-protein diet is not a standard intervention for COPD. Early-morning hours are generally not recommended for exercise due to cooler temperatures and higher pollution levels, which can exacerbate COPD symptoms.
2. What should the nurse prioritize when monitoring an older adult client immediately following a bronchoscopy?
- A. Observing for confusion
- B. Auscultating breath sounds
- C. Confirming the gag reflex
- D. Measuring blood pressure
Correct answer: C
Rationale: Following a bronchoscopy, the priority for the nurse is to confirm the gag reflex in the older adult client. This is crucial to ensure that the client's airway is protected and free from any obstruction or aspiration. Monitoring the gag reflex helps in preventing complications such as aspiration pneumonia. While auscultating breath sounds, observing for confusion, and measuring blood pressure are important assessments, confirming the gag reflex takes precedence in this situation to maintain airway patency and prevent potential respiratory complications.
3. A client has burns to his face, ears, and eyelids. What is the priority finding for the nurse to report to the provider?
- A. Urinary output of 25 mL/hr
- B. Difficulty swallowing
- C. Heart rate of 122/min
- D. Pain level of 6 on a scale of 0 to 10
Correct answer: B
Rationale: When a client has burns involving the face, ears, and eyelids, the priority finding to report to the provider is difficulty swallowing. This symptom could indicate potential airway compromise or swelling in the throat, which can lead to serious complications. Monitoring and addressing this issue promptly is crucial to ensure the client's airway remains patent and secure.
4. A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?
- A. Increase the oxygen flow to 3 L/min.
- B. Assess the client's respiratory status.
- C. Call emergency services for the client.
- D. Have the client cough and expectorate secretions.
Correct answer: B
Rationale: When a client with COPD on oxygen therapy reports difficulty breathing, the priority action for the nurse is to assess the client's respiratory status. This involves evaluating the client's oxygen saturation levels, respiratory rate, effort of breathing, lung sounds, and overall respiratory distress. By assessing the client's respiratory status, the nurse can determine the severity of the situation and make appropriate decisions regarding further interventions, such as adjusting oxygen flow rate, providing respiratory treatments, or seeking emergency assistance if necessary.
5. A client with tuberculosis is starting combination drug therapy. Which of the following medications should the nurse NOT plan to administer?
- A. Rifampin
- B. Isoniazid
- C. Acyclovir
- D. Pyrazinamide
Correct answer: C
Rationale: Acyclovir is an antiviral medication used to treat herpes virus infections, not tuberculosis. Rifampin, Isoniazid, and Pyrazinamide are all commonly used in the treatment of tuberculosis. Therefore, the nurse should not plan to administer Acyclovir to a client with tuberculosis.
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