ATI RN
Medical Surgical ATI Proctored Exam
1. A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?
- A. Severe dyspnea
- B. Nausea
- C. Decreased level of consciousness
- D. Headache
Correct answer: B
Rationale: In acute respiratory failure, the body is not getting enough oxygen, leading to hypoxia. Symptoms of hypoxia include severe dyspnea (A), decreased level of consciousness (C), and headache (D) due to inadequate oxygen supply to the brain. Nausea (B) is not a typical manifestation of acute respiratory failure and is not directly related to the lack of oxygen in the body. Therefore, the nurse should not monitor the client for nausea as a direct consequence of ARF.
2. During an assessment in the emergency department, an older adult client with community-acquired pneumonia is found to be confused. Which of the following findings should the nurse expect?
- A. Unequal pupils
- B. Hypertension
- C. Tympany upon chest percussion
- D. Confusion
Correct answer: D
Rationale: Confusion is a common finding in older adult clients with pneumonia, often indicating hypoxia. Hypertension, unequal pupils, and tympany upon chest percussion are not typically associated with community-acquired pneumonia in older adults.
3. A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
- A. Perform suctioning for up to four passes.
- B. Apply suction to the catheter when advancing it into the trachea.
- C. Preoxygenate the client with 100% oxygen for up to 3 min.
- D. Limit each suction pass to 25 seconds.
Correct answer: C
Rationale:
4. A client who is receiving mechanical ventilation and has an ideal weight of 60 kg should have the tidal volume set at which of the following?
- A. 300 mL
- B. 480 mL
- C. 800 mL
- D. 950 mL
Correct answer: B
Rationale: Tidal volume is the amount of air delivered with each breath during mechanical ventilation. A common formula used to calculate tidal volume is 6-8 mL/kg of ideal body weight. For a client with an ideal weight of 60 kg, the expected tidal volume would be 60 kg x 6-8 mL/kg = 360-480 mL. Therefore, the most appropriate choice is 480 mL (Option B), which falls within the expected range based on the client's weight.
5. 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.
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