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 male client has returned to the Unit following a left femoral popliteal bypass graft. Six hours later, the client's dorsalis pedis pulse cannot be palpated and his foot is cool and dusky. The nurse should:

  • A. continue to monitor the foot.
  • B. immediately notify the physician.
  • C. notify the head nurse.
  • D. assure the client that his foot is fine.
Correct Answer: B

Rationale: The client is losing the blood supply to his left foot. Continuing to monitor will not restore the blood supply to the foot. The physician should be notified immediately because the client is losing the blood supply to his left foot and is in danger of losing his foot and/or his leg. It is the responsibility of the nurse caring for the client to notify the physician, not the head nurse. This would be giving the client false assurances, which is unethical, demeaning, and could have legal consequences.

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To offer the most effective program with the best outcomes, the nurses should initially

  • A. Search for an article that describes nursing interventions that are effective for smoking cessation
  • B. Develop a clinical question that will allow them to compare different cessation methods during the program
  • C. Keep comprehensive records that detail each patient’s progress and ultimate outcomes from participation in the program
  • D. Use evidence-based clinical practice guidelines developed from reviews of randomized controlled trials of smoking cessation methods
Correct Answer: D

Rationale: Using evidence-based guidelines ensures the program is grounded in proven methodologies, leading to better outcomes.

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.

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.

What would be useful in helping Mr. Jackson prepare for chest tube insertion?

  • A. Explain the etiology of his condition
  • B. Ask if he has any questions about the insertion procedure and its purpose
  • C. Teach him to splint his chest wall
  • D. Reassure him that the procedure is painless
Correct Answer: C

Rationale: Splinting minimizes movement and discomfort during the procedure.

Which task is most appropriate to delegate to an LPN /LVN?

  • A. Talk to a community group about water safety issues
  • B. Stabilize the cervical spine for an unconscious drowning victim
  • C. Remove wet clothing and cover the victim with a warm blanket
  • D. Monitor an asymptomatic near-drowning victim
Correct Answer: C

Rationale: Removing wet clothing and covering the victim with a warm blanket is a straightforward task suitable for an LPN/LVN.

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