ATI RN
Medical Surgical ATI Proctored Exam
1. 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.
2. 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.
3. 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.
4. A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?
- A. Pigeon
- B. Funnel
- C. Kyphotic
- D. Barrel
Correct answer: D
Rationale:
5. A healthcare provider is assessing a client immediately after the removal of the endotracheal tube. Which of the following findings should the provider report to the healthcare provider?
- A. Stridor
- B. Copious oral secretions
- C. Hoarseness
- D. Sore throat
Correct answer: A
Rationale: Stridor is a high-pitched, harsh respiratory sound that can indicate airway obstruction. It is a serious finding that requires immediate attention as it may lead to respiratory compromise. Copious oral secretions, hoarseness, and sore throat are common but expected findings after endotracheal tube removal and do not typically require urgent intervention.
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