ATI RN
Medical Surgical ATI Proctored Exam
1. While dining at a restaurant, a person begins to choke. Which of the following actions should the nurse take?
- A. Instruct the person to call 911.
- B. Ask the person if he/she can speak.
- C. Use the jaw-thrust maneuver.
- D. Perform abdominal thrusts.
Correct answer: B
Rationale: When encountering a choking individual, the nurse should first assess the person's ability to speak. If the person can speak, it indicates that their airway is partially obstructed, allowing some air to pass. In this case, encouraging the person to continue coughing and monitoring them closely may be appropriate. If the person cannot speak, it may suggest a complete airway obstruction and immediate intervention is required. Instructing the person to call 911 (Choice A) may be necessary if the situation worsens. Using the jaw-thrust maneuver (Choice C) is not appropriate for a choking victim. Performing abdominal thrusts (Choice D) is typically recommended for conscious choking victims, not chest compressions.
2. While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
- A. Airway obstruction
- B. Infection
- C. Fluid imbalance
- D. Paralytic ileus
Correct answer: A
Rationale: When a client sustains burns to the head, neck, or chest, the risk of airway obstruction is a critical concern due to potential swelling, inflammation, or inhalation injury. Any compromise to the airway can lead to severe respiratory distress or failure. Early recognition and intervention to maintain a clear airway are essential to prevent life-threatening complications in burn patients.
3. What question should a nurse ask a client who has an anteroposterior (AP) chest diameter equal to the lateral chest diameter?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercise?
- D. What is your occupation and what are your hobbies?
Correct answer: B
Rationale: The correct answer is B. A nurse should ask the client if they have any chronic breathing problems when the anteroposterior (AP) chest diameter is the same as the lateral chest diameter. This finding indicates a barrel chest, which can be associated with chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD) or emphysema. Assessing for chronic breathing problems can help the nurse further evaluate the client's respiratory status and provide appropriate care.
4. 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:
5. A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?
- A. Withhold food and liquids until the client's gag reflex returns.
- B. Irrigate the client's throat every 4 hours.
- C. Have the client refrain from talking for 24 hours.
- D. Suction the client's oropharynx frequently.
Correct answer: A
Rationale: After a flexible bronchoscopy, it is crucial to withhold food and liquids until the client's gag reflex returns to prevent aspiration. Irrigating the client's throat every 4 hours, having the client refrain from talking for 24 hours, and frequent suctioning of the oropharynx are not indicated post-bronchoscopy and may even pose risks to the client's recovery.
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