ATI RN
ATI Detailed Answer Key Medical Surgical
1. A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Decreased serum calcium level
- B. Decreased level of serum lipids
- C. Decreased erythrocyte sedimentation rate (ESR)
- D. Increased platelet count
Correct answer: A
Rationale: In fat embolism syndrome (FES), fat globules enter the bloodstream and can lead to various complications, including a decrease in serum calcium levels. This occurs due to the formation of fat emboli in the vessels, which can interfere with calcium metabolism. Therefore, a decreased serum calcium level is an expected laboratory finding in a client with fat embolism syndrome.
2. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?
- A. Night sweats
- B. Low-grade fever
- C. Weight gain
- D. Blood in the sputum
Correct answer: C
Rationale:
3. A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?
- A. Assess the client's lung sounds.
- B. Call the Rapid Response Team.
- C. Have the client sit upright.
- D. Listen to the client's lung sounds.
Correct answer: A
Rationale: The sound described is an S3 heart sound, which can indicate heart failure. The next appropriate action for the provider is to listen to the client's lung sounds. Lung sounds can provide additional information about the client's condition, especially when abnormal heart sounds are present. Calling the Rapid Response Team is not warranted based solely on the heart sound assessment. Having the client sit upright is not directly related to addressing the abnormal heart sound.
4. A client had a bronchoscopy 2 hours ago and asks for a drink of water. Which action should the nurse take next?
- A. Call the healthcare provider to request a prescription for food and water.
- B. Provide the client with ice chips instead of a drink of water.
- C. Assess the client's gag reflex before giving any food or water.
- D. Let the client have a small sip to assess swallowing ability.
Correct answer: C
Rationale: After a bronchoscopy, a topical anesthetic affects the gag reflex. Therefore, the nurse should assess the client's gag reflex before providing any food or water to ensure its return. This assessment is crucial to prevent aspiration or choking risk in the client.
5. A client with a tracheostomy experienced a coughing spell during a meal that was being fed by an unlicensed assistive personnel (UAP). What action by the nurse takes priority?
- A. Assess the client's lung sounds.
- B. Assign a different UAP to the client.
- C. Report the UAP to the manager.
- D. Request thicker liquids for meals.
Correct answer: A
Rationale: The priority action for the nurse is to assess the client's lung sounds to check for signs of aspiration, which can compromise the client's oxygenation. This is crucial to ensure the client's immediate safety and respiratory status. Once the client has been assessed, the nurse can then consider consulting with the registered dietitian regarding appropriate thickened liquids for future meals. Assigning a different UAP or reporting the UAP to the manager may be necessary steps but not the immediate priority in this situation.
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