ATI Detailed Answer Key Medical Surgical

ATI Detailed Answer Key Medical Surgical Related

Review ATI Detailed Answer Key Medical Surgical related questions and content

The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?

  • A. Fluctuation of the fluid level within the water seal chamber
  • B. Absence of fluid in the drainage tubing
  • C. Continuous bubbling within the water seal chamber
  • D. Equal amounts of fluid drainage in each collection chamber
Correct Answer: A

Rationale: The correct answer is A: Fluctuation of the fluid level within the water seal chamber. This indicates proper chest tube function as it shows that the system is maintaining the desired pressure and allowing for adequate drainage without obstruction. When the patient breathes in and out, the fluid level fluctuates due to changes in intrathoracic pressure.

Explanation of other choices:
B: Absence of fluid in the drainage tubing - This would indicate a problem with drainage, possibly due to a blockage in the tubing.
C: Continuous bubbling within the water seal chamber - This would suggest an air leak in the system, which is not ideal as it can lead to lung collapse.
D: Equal amounts of fluid drainage in each collection chamber - While equal drainage is good, it does not specifically indicate proper chest tube function like the fluctuation of the fluid level does.

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Your patient is experiencing exacerbations of systemic lupus erythematosus. What would you expect the physician to prescribe?

  • A. Antiemetics.
  • B. Corticosteroids.
  • C. Antineoplastics.
  • D. Antibiotics.
Correct Answer: B

Rationale: Corticosteroids are used to manage SLE flare-ups.

A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

  • A. Raise the foot of the bed to a 90° angle
  • B. Remove the dressing to inspect the wound
  • C. Prepare to insert a central line
  • D. Administer oxygen via nasal cannula
Correct Answer: D

Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration.

A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation.
B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity.
C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.

What volume of fluid loss causes marked deterioration in hypovolemic shock?

  • A. 30% to 40% (1500 mL to 2000 mL)
  • B. 15% to 30% (750 mL to 1500 mL)
  • C. 10% to 15% (500 mL to 750 mL)
  • D. More than 40% (more than 2000 mL)
Correct Answer: B

Rationale: Loss of 15% to 30% of blood volume significantly impairs circulation and tissue perfusion.

Sue has a mild dermatitis rash and asks for advice. You respond by saying

  • A. Wash the area with an antiseptic soap frequently to keep the area clean.
  • B. Use an antifungal ointment.
  • C. Use talcum powder to soothe the inflamed skin.
  • D. Use a mild steroidal cream.
Correct Answer: D

Rationale: Steroidal creams reduce inflammation in dermatitis.

A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?

  • A. Patency of the intravenous line
  • B. Level of pain
  • C. Integrity of the dressing
  • D. Need for suctioning
Correct Answer: D

Rationale: The correct answer is D: Need for suctioning. After a laryngectomy, maintaining a clear airway is crucial to prevent aspiration and ensure proper oxygenation. Suctioning helps remove secretions and maintain airway patency. Monitoring for signs of respiratory distress is essential.

A: Patency of the intravenous line is important but not the priority over airway management.
B: Level of pain is important but not as critical as ensuring a clear airway.
C: Integrity of the dressing is important for wound healing but does not directly impact airway patency.

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