Adult Medical Surgical ATI

Adult Medical Surgical ATI Related

Review Adult Medical Surgical ATI related questions and content

During pulmonary hygiene for a client with pneumonia, a nurse positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?

  • A. Lateral segment of the left lower lobe
  • B. Lateral segment of the right lower lobe
  • C. Posterior segment of the right middle lobe
  • D. Posterior segment of the right lower lobe
Correct Answer: B

Rationale: The correct answer is B: Lateral segment of the right lower lobe. In Trendelenburg position on the left side, gravity helps drain secretions from the right lung's lateral segments more effectively. The right lower lobe's lateral segment is the most dependent part of the lung in this position, facilitating secretion mobilization. Choices A, C, and D are incorrect because they do not align with the gravitational effect in Trendelenburg position on the left side, making secretion mobilization less efficient in those segments.

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What is an example of a pertinent negative finding during a physical examination?

  • A. Chest pain that does not radiate to the arm
  • B. Elevated blood pressure in a patient with hypertension
  • C. Pupils that are equal and react to light and accommodation
  • D. Clear and full lung sounds in a patient with chronic bronchitis
Correct Answer: A

Rationale: The correct answer is 'Chest pain that does not radiate to the arm.' Pertinent negatives highlight clinically significant absences of expected findings, helping rule out certain conditions like cardiac ischemia.

What would be the best response by the nurse to a quiet and uncommunicative client?

  • A. Think over the following questions.
  • B. Discuss them with your instructor or peers.
  • C. Acknowledge their feelings and encourage expression.
  • D. Offer silence and wait patiently.
Correct Answer: D

Rationale: Silence can provide the client with space to open up when they feel ready, fostering trust and rapport.

The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?

  • A. Cough and deep breathe every 2 hours.
  • B. Place the client in contact isolation.
  • C. Provide a diet high in protein.
  • D. Institute seizure precautions.
Correct Answer: A

Rationale: Encouraging coughing and deep breathing helps prevent pulmonary complications.

For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?

  • A. Impaired skin integrity related to incision
  • B. Impaired mobility related to decreased muscle strength
  • C. Risk for aspiration related to decreased muscle strength
  • D. Ineffective airway clearance related to decreased respiratory excursion
Correct Answer: D

Rationale: Ambulation addresses multiple postoperative issues, including mobility, respiratory function, constipation, and thromboembolism prevention.

A client is vomiting. Which of the following actions should the nurse take first?

  • A. Provide the client with an emesis basin
  • B. Notify housekeeping
  • C. Prevent the client from aspirating
  • D. Administer an antiemetic to the client
Correct Answer: C

Rationale: The correct action for the nurse to take first is to prevent the client from aspirating. Aspiration is a serious risk when a client is vomiting as it can lead to respiratory complications. The nurse should position the client on their side to prevent aspiration of vomitus into the airway. This immediate action takes priority over providing an emesis basin, notifying housekeeping, or administering an antiemetic, which do not address the urgent need to prevent aspiration.

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