ATI RN
ATI Detailed Answer Key Medical Surgical
1. While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
- A. It decreases the client's level of anxiety.
- B. It facilitates the client's deep breathing.
- C. It enhances the client's ability to sleep.
- D. It reduces the client's blood pressure.
Correct answer: B
Rationale: In the postoperative period following CABG surgery, deep breathing exercises are essential to prevent complications such as atelectasis and pneumonia. Opioid medications can depress the respiratory system, making it crucial for the nurse to emphasize the importance of deep breathing to maintain optimal lung function. While managing pain and anxiety are important, facilitating deep breathing takes precedence in this situation to promote effective recovery and prevent respiratory complications.
2. After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
- B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
Correct answer: C
Rationale: Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages, making option C the correct match. Wheezes are typically heard in the central or peripheral lung areas and are associated with conditions like asthma or COPD. Inhaled bronchodilators work by dilating the bronchioles, which helps alleviate wheezing and improve airflow. Therefore, administering an inhaled bronchodilator is the appropriate intervention in response to wheezes.
3. A client has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
- A. Never strip the tubing to maintain patency.
- B. Secure tubing junctions with tape to prevent accidental disconnections.
- C. Set wall suction at the level recommended by the device manufacturer.
- D. Keep padded clamps at the bedside for use if the drainage system is interrupted.
Correct answer: D
Rationale: To ensure safe use of a pleural chest tube, the nurse should keep padded clamps at the bedside for use if the drainage system becomes dislodged or is interrupted. Stripping the tubing should never be done to maintain patency. Tubing junctions should be secured with tape, not clamps. Wall suction should be set at the level recommended by the device manufacturer, not the provider.
4. A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?
- A. "We can teach you some relaxation techniques to minimize your pain."
- B. "Keep wire cutters with you at all times."
- C. "Use a water pick device to keep your teeth clean."
- D. "Consume a high-protein, liquid diet."
Correct answer: B
Rationale:
5. A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?
- A. "It might help if I tried sleeping only on my back."
- B. "I'll sleep better if I take a sleeping pill at night."
- C. "I'll get a humidifier to run at my bedside at night."
- D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
Correct answer: D
Rationale:
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