ATI Detailed Answer Key Medical Surgical

ATI Detailed Answer Key Medical Surgical Related

Review ATI Detailed Answer Key Medical Surgical related questions and content

A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

  • A. Prevent aspiration.
  • B. Ensure adequate nutrition.
  • C. Promote oral hygiene.
  • D. Relieve the client's pain.
Correct Answer: A

Rationale: The correct answer is A: Prevent aspiration. This is the priority because with intermaxillary fixation, the client is unable to open their mouth, increasing the risk of aspiration. Aspiration can lead to serious complications, such as pneumonia. Ensuring the client's airway is clear and they are able to breathe properly should be the top priority.

Summary:
- B: Ensuring adequate nutrition can be important, but preventing aspiration takes precedence.
- C: Promoting oral hygiene is important but not as urgent as preventing aspiration.
- D: Relieving the client's pain is essential, but ensuring their safety from aspiration is the priority.

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A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?

  • A. S3 heart sound.
  • B. Thready pulse.
  • C. Flattened neck veins.
  • D. Hypoventilation.
Correct Answer: A

Rationale: An S3 heart sound indicates volume overload.

Match the descriptions to the stages of sleep. Some descriptions may have more than one stage and some stages may be used more than once.

  • A. Brain waves resemble wakefulness
  • B. Deepest sleep, lasting 20 to 40 minutes
  • C. Associated with specific EEG waveforms
  • D. Most vivid dreaming occurs
Correct Answer: D

Rationale: The correct answer is D (REM). REM sleep is characterized by brain waves resembling wakefulness and vivid dreaming. The deepest sleep (B) corresponds to NREM Stage 3, while specific EEG waveforms (C) are associated with all stages.

Symptoms of an ectopic pregnancy include:

  • A. Hematuria, pelvic pain, and dizziness
  • B. Amenorrhea, pelvic pain, and vaginal spotting
  • C. Constipation, nausea, and fainting
  • D. Fallopian pain, nausea, and breast enlargement
Correct Answer: B

Rationale: Ectopic pregnancies often present with amenorrhea, pelvic pain, and vaginal spotting due to the abnormal implantation site.

A client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant?

  • A. Administer IV fluids as prescribed by the physician.
  • B. Provide straws and offer fluids between meals.
  • C. Develop plan for added fluid intake over 24 hours.
  • D. Teach family members to assist client with fluid intake.
Correct Answer: B

Rationale: The nursing assistant can effectively encourage oral fluid intake by offering fluids between meals, which is within their scope of practice. Administering IV fluids, developing plans, and teaching family members are more advanced tasks that require higher-level nursing skills.

In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to:

  • A. Avoid overheating during physical activities.
  • B. Maintain normal activity with some restrictions.
  • C. Be cautious of others with viruses or temperatures.
  • D. Maintain routine immunizations.
Correct Answer: D

Rationale: Immunizations protect against infections that can trigger crises.

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