ATI RN
Medical Surgical ATI Proctored Exam
1. A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?
- A. Rest in a side-lying position after the tube is removed.
- B. Use the incentive spirometer every 4 hours after the tube is removed.
- C. Avoid speaking for extended periods.
- D. Vital signs will be monitored by a nurse every 15 minutes in the first hour after the tube is removed.
Correct answer: C
Rationale: It is essential to advise the client to avoid speaking for extended periods after the removal of the endotracheal tube to prevent strain on the vocal cords and allow the airway to recover. Speaking for prolonged periods can lead to irritation and potentially affect the healing process. The other options are also important post-extubation instructions, such as using the incentive spirometer to maintain lung function, positioning in a side-lying position for comfort, and frequent monitoring of vital signs to ensure the client's stability.
2. A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. Widened QRS complexes
- B. Hyperactive deep tendon reflexes
- C. Bounding peripheral pulses
- D. Warm, flushed skin
Correct answer: A
Rationale: Respiratory acidosis is a condition characterized by increased carbon dioxide levels in the blood, resulting in acidosis. One of the potential consequences of respiratory acidosis is the development of electrolyte imbalances, particularly hyperkalemia. Hyperkalemia can lead to cardiac conduction abnormalities, manifested as widened QRS complexes on an electrocardiogram (ECG). Therefore, in a client with respiratory acidosis, the healthcare professional should expect to find widened QRS complexes as a result of the associated hyperkalemia.
3. 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.
4. While assessing a client with pulmonary tuberculosis, which of the following findings should the nurse expect?
- A. Lethargy
- B. High-grade fever
- C. Weight gain
- D. Dry cough
Correct answer: A
Rationale: When assessing a client with pulmonary tuberculosis, the nurse should expect lethargy as a common finding. Tuberculosis can cause fatigue and weakness due to the body's efforts to fight the infection. High-grade fever is another common symptom of tuberculosis, not weight gain or dry cough. Weight loss is more typical in tuberculosis due to decreased appetite and systemic effects of the infection. A persistent productive cough with sputum is more characteristic of tuberculosis rather than a dry cough.
5. A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should not base her actions on which of the following information?
- A. The student should use his quick-relief inhaler.
- B. The student's asthma is not well controlled.
- C. The student's peak flow is 50% to 80% of his best peak flow.
- D. The student needs to go to the hospital
Correct answer: D
Rationale: In an asthma action plan, the yellow zone indicates caution and signals a need to monitor symptoms closely. When a student is in the yellow zone, the appropriate action is to follow the prescribed steps, which typically include using a quick-relief inhaler and closely monitoring peak flow. Going to the hospital is usually reserved for severe asthma exacerbations in the red zone. Therefore, the information that the student needs to go to the hospital is not typically appropriate when the student is in the yellow zone.
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