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 nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

  • A. Insert an indwelling urinary catheter.
  • B. Inspect the mouth for signs of inhalation injuries.
  • C. Administer intravenous pain medication.
  • D. Draw blood for a complete blood cell (CBC) count.
Correct Answer: B

Rationale: The correct answer is B: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening due to airway compromise. The nurse should assess for soot in the mouth, facial burns, hoarseness, and difficulty breathing. This allows for prompt intervention if respiratory distress is present.

A: Inserting an indwelling urinary catheter is not the priority as it does not address the immediate life-threatening issue.
C: Administering pain medication is important but not the priority over assessing for inhalation injuries which could lead to respiratory distress.
D: Drawing blood for a CBC count is not the priority as it does not address the immediate threat to the client's airway.

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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.

In assigning patients with alterations related to gastrointestinal (GI) cancer, which would be the most appropriate nursing care tasks to assign to the LPN/LVN, under supervision of the team leader RN?

  • A. A patient with severe anemia secondary to GI bleeding.
  • B. A patient who needs enemas and antibiotics to control GI bacteria.
  • C. A patient who needs pre-op teaching for bowel resection surgery.
  • D. A patient who needs central line insertion for chemotherapy.
Correct Answer: B

Rationale: Administering enemas and antibiotics involves routine tasks that LPNs/LVNs are trained to perform, whereas the other options require advanced skills or supervision.

A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

  • A. Continue to monitor the client as this is an expected finding.
  • B. Add more water to the suction control chamber of the drainage system.
  • C. Verify that the suction regulator is on and check the tubing for leaks.
  • D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
Correct Answer: C

Rationale: The correct answer is C: Verify that the suction regulator is on and check the tubing for leaks.

Rationale:
1. Lack of bubbling in the suction control chamber indicates suction may not be working.
2. Checking the suction regulator ensures it is on and at the correct level for proper drainage.
3. Checking tubing for leaks ensures the system is intact and functioning properly.
4. This intervention addresses the potential issue of inadequate suction, which can affect the client's postoperative recovery.

Summary:
- Option A: Continuing to monitor is not appropriate as lack of bubbling suggests an issue with suction.
- Option B: Adding more water to the suction control chamber is unnecessary and does not address the root cause.
- Option D: Milking the chest tube is not recommended as it can cause trauma and dislodging clots may lead to complications.

While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient’s heel. During care of the ulcer, what is the nurse’s understanding of the patient’s perception of pain?

  • A. The patient will have a behavioral response if pain is perceived.
  • B. The area should be treated as a painful lesion, using gentle cleansing and dressing.
  • C. The area can be thoroughly scrubbed because the patient is not able to perceive pain.
  • D. All nociceptive stimuli that are transmitted to the brain result in the perception of pain.
Correct Answer: B

Rationale: The correct answer is B. Even in unconscious patients, the area should be treated gently to avoid exacerbating potential pain.

What complication can result from tracheal suctioning?

  • A. Acute hypoxemia
  • B. Gastric dilatation
  • C. Hypervolemic shock
  • D. Epiglottitis
Correct Answer: A

Rationale: Suctioning temporarily reduces oxygen levels, necessitating careful monitoring.

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