ATI RN
ATI Detailed Answer Key Medical Surgical
1. A healthcare worker is caring for a group of clients in an infectious disease unit. The worker should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?
- A. Pertussis
- B. Mycoplasma pneumonia
- C. Tuberculosis
- D. Respiratory syncytial virus
Correct answer: C
Rationale: An OSHA-approved N95 respirator mask is recommended when caring for a client with tuberculosis due to the airborne transmission of the disease. Tuberculosis poses a higher risk of transmission via respiratory droplets, making respiratory protection essential to prevent exposure and infection among healthcare workers.
2. A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
- A. Pain severity
- B. Wound drainage
- C. Tissue integrity
- D. Airway patency
Correct answer: D
Rationale: In a client following a partial laryngectomy, the priority assessment is always airway patency. This is crucial to ensure that the client can breathe adequately and prevent any complications related to airway obstruction. Monitoring airway patency takes precedence over other assessments such as pain severity, wound drainage, and tissue integrity. Any compromise in airway patency requires immediate intervention to maintain the client's respiratory function and safety.
3. During an admission assessment of a client with COPD and emphysema complaining of a frequent productive cough and shortness of breath, what assessment finding should the nurse anticipate?
- A. Respiratory alkalosis
- B. Increased anteroposterior diameter of the chest
- C. Oxygen saturation level 96%
- D. Petechiae on chest
Correct answer: B
Rationale: COPD and emphysema are chronic respiratory conditions that can lead to changes in the shape of the chest. In clients with COPD, the anteroposterior diameter of the chest often increases, giving a barrel chest appearance. This change in chest shape is due to hyperinflation of the lungs and is a common physical finding in clients with COPD and emphysema. The other options are not typically associated with COPD and emphysema. Respiratory alkalosis is not a common finding in these clients. An oxygen saturation level of 96% is within the normal range and does not specifically relate to COPD. Petechiae on the chest are not typically associated with COPD or emphysema.
4. A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?
- A. Do you have a strong support system?
- B. What do you understand about your disease?
- C. Do you experience shortness of breath with basic activities?
- D. What medications are you prescribed to take each day?
Correct answer: C
Rationale: In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.
5. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct answer: A
Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.
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