Medical Surgical ATI Proctored Exam

Medical Surgical ATI Proctored Exam Related

Review Medical Surgical ATI Proctored Exam related questions and content

A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

  • A. Rest in a side-lying position after the tube is removed.
  • B. Use the incentive spirometer every 4 hours after the tube is removed.
  • C. Avoid speaking for extended periods.
  • D. Vital signs will be monitored by a nurse every 15 minutes in the first hour after the tube is removed.
Correct Answer: C

Rationale: The correct answer is C: Avoid speaking for extended periods. This instruction is important to prevent strain on the vocal cords and reduce the risk of aspiration or airway irritation post-extubation. Speaking after the removal of the endotracheal tube can potentially lead to complications.

Step-by-step rationale:
1. Speaking can cause strain on the vocal cords, which may lead to hoarseness or damage.
2. It is essential to allow the airway to recover and prevent irritation or inflammation.
3. Resting the voice can aid in the healing process and reduce the risk of complications.
4. Incentive spirometer use (option B) is important for lung expansion but not directly related to vocal cord rest.
5. Vital signs monitoring (option D) is crucial but does not address vocal cord care or prevention of complications.
6. Resting in a side-lying position (option A) is not directly related to vocal cord rest or post-extubation care.

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Which of the following is a definitive sign of pregnancy?

  • A. Amenorrhea
  • B. Positive hCG
  • C. Morning sickness
  • D. Fetal heart sounds
Correct Answer: D

Rationale: Fetal heart sounds are a definitive sign of pregnancy, confirming the presence of a viable fetus.

A 43-year-old man came to the ED reporting that for short periods of time he feels detached from his body and sometimes he feels like he is floating. The patient states he had not taken any drugs and his drug toxicology test results are negative. What is your best response?

  • A. Does this condition interfere with activities of daily living?
  • B. Did you ever take hallucinogenic at any time in your life?
  • C. Let me ask our psychiatrist to assess you.
  • D. Do you have any other symptoms?
Correct Answer: C

Rationale: Referral to a psychiatrist addresses potential underlying psychiatric conditions causing these symptoms.

Several cultural groups avoid direct eye contact and consider it disrespectful or aggressive. Which cultural group may not return a direct gaze?

  • A. Arab
  • B. Asian
  • C. Hispanic
  • D. Native American
Correct Answer: B

Rationale: In many Asian cultures, avoiding direct eye contact signifies respect, particularly toward authority figures or elders.

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

  • A. Pigeon
  • B. Funnel
  • C. Kyphotic
  • D. Barrel
Correct Answer: D

Rationale: The correct answer is D: Barrel. In COPD, the chest becomes barrel-shaped due to hyperinflation of the lungs. This results in an increased anterior-posterior chest diameter, giving it a rounded appearance. This shape is characteristic of COPD as the hyperinflation causes the rib cage to remain partially expanded at all times.

A: Pigeon – This shape is not associated with COPD and is not a typical finding in respiratory conditions.
B: Funnel – This shape is not associated with COPD and is more commonly seen in conditions like pectus excavatum.
C: Kyphotic – This shape refers to an exaggerated outward curvature of the thoracic spine, not the chest shape itself.

The nurse knows that the most likely cause of the HSV-1 infection in a client with HIV infection is:

  • A. Immunosuppression.
  • B. Emotional stress.
  • C. Unprotected sexual activities.
  • D. Contact with saliva.
Correct Answer: A

Rationale: HSV-1 thrives in immunocompromised individuals due to weakened immune defenses.

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