ATI Comprehensive Medical Surgical Exam

Correct Answer B. Cleanse the wound from the inside toward the outside

Explanation

The correct technique for wound cleansing is to move from the least contaminated area to the most contaminated area. This means cleaning from the center (or inside) of the wound outward toward the surrounding skin. This method reduces the risk of introducing bacteria from the surrounding skin into the wound bed and promotes proper healing.

Why Other Options Are Wrong

A. Irrigate noninfected wounds with sterile water

Sterile normal saline—not sterile water—is the preferred irrigant for noninfected wounds. It is isotonic and does not harm tissue. Sterile water can cause cell damage due to its hypotonic nature.

C. Pat the wound dry immediately after cleansing it

Wounds should generally be allowed to air dry slightly or be gently blotted if directed, but aggressive drying can disturb granulation tissue or introduce contaminants. Drying is not always appropriate, especially for wounds being treated with moist healing strategies.

D. Warm the irrigant in a microwave prior to cleansing the wound

Microwaving irrigant solutions is unsafe because it can lead to uneven heating and potential tissue burns. If warming is necessary, the solution should be placed in a warm water bath and checked for appropriate temperature

Correct Answer B. Notify the provider about the client's wishes.

Explanation

Autonomy is the ethical principle that recognizes the client’s right to make their own healthcare decisions. If a client changes their mind about a procedure, the nurse must respect that decision and promptly inform the provider. The client has the legal and ethical right to refuse treatment, even if that treatment is life-saving.

Why Other Options Are Wrong

A. Inform the client that his power of attorney will be notified

This is unnecessary unless the client lacks decision-making capacity. As long as the client is competent, their own decision takes priority.

C. Have the hospital chaplain talk with the client

Offering spiritual support may be helpful, but it is not the nurse’s first action and could be seen as an attempt to persuade the client.

D. Inform the client that his condition will become worse

This could be coercive or fear-inducing, and it does not support the client’s autonomy. The nurse’s role is to provide nonjudgmental support and information, not pressure.

Correct Answer A. Maintain the client's sodium intake at 3 g per day.

Explanation

Clients with cirrhosis, especially those with ascites or edema, require sodium restriction to reduce fluid retention. While less than 2 grams per day is often ideal in severe cases, up to 3 grams per day is acceptable in moderate sodium restriction, depending on the provider’s prescription and the client’s condition.

This level can help minimize ascites and edema without being overly restrictive, which may affect nutritional intake and adherence.

Why Other Options Are Wrong

B. Measure the client's chest circumference daily

This is not relevant to cirrhosis care. Abdominal girth, not chest circumference, is measured to monitor ascites.

C. Have the client stay in a supine position while in bed

This can worsen dyspnea and discomfort, especially in clients with ascites. A semi-Fowler’s or Fowler’s position is preferred.

D. Keep the client's feet in an elevated position

While elevation may help with peripheral edema, it does not address the primary concern in cirrhosis, which is fluid retention in the abdomen (ascites) rather than the legs alone.

Correct Answer A. I will take a missed dose as soon as I remember it.

Explanation

If a client misses a dose of warfarin, they should take it as soon as they remember on the same day. However, they should not double the dose the next day. This statement reflects proper understanding of medication adherence and timing.

Why Other Options Are Wrong

B. I will avoid foods that are high in vitamin E.

Clients on warfarin should be more concerned about vitamin K, not E. Vitamin K can counteract warfarin’s effects.

C. I can take ginseng supplements to improve my memory.

Ginseng can interfere with warfarin and increase the risk of bleeding or decrease effectiveness. It should be avoided unless cleared by a provider.

D. I should expect to have bleeding gums while taking this medication.

Bleeding gums may indicate excess anticoagulation and are not expected. This is a warning sign of potential bleeding complications and should be reported.

Correct Answer C. Atropine

Explanation

Atropine is the first-line medication used to treat symptomatic sinus bradycardia. It works by blocking the vagus nerve's effect on the heart, increasing the heart rate. In clients with bradycardia following a myocardial infarction, prompt administration of atropine can help restore adequate cardiac output.

Why Other Options Are Wrong

A. Digoxin

Digoxin slows the heart rate and increases cardiac contractility. It is contraindicated in bradycardia, as it could worsen the condition.

B. Propranolol

Propranolol is a beta-blocker that further decreases the heart rate and is not appropriate in cases of bradycardia.

D. Adenosine

Adenosine is used to treat supraventricular tachycardia (SVT), not bradycardia. It temporarily slows conduction through the AV node and would worsen a slow heart rate.

Correct Answer D. A client experiences permanent lower limb paralysis following a lumbar laminectomy.

Explanation

A sentinel event is an unexpected occurrence involving serious physical or psychological injury or death. Permanent lower limb paralysis after a procedure like a lumbar laminectomy is a significant, unexpected outcome and fits the definition. It requires a root cause analysis to determine preventable factors.

Why Other Options Are Wrong

A. A client is brought to the emergency department after a suicide attempt at home

This is not a sentinel event within the facility unless the suicide attempt happened during hospitalization or under the facility’s care.

B. A client develops diarrhea following administration of sodium polystyrene sulfonate

Diarrhea is a common, expected side effect of this medication and not a sentinel event.

C. A client decides not to have surgery after receiving a preoperative dose of lorazepam

This reflects a change in client decision-making and potential informed consent concerns but not a sentinel event unless harm occurs.

Correct Answer D. Minimize the number of venipunctures the client receives.

Explanation

Thrombolytic therapy increases the client's risk for bleeding due to its clot-dissolving effects. To reduce this risk, the nurse should limit invasive procedures such as venipunctures. When blood draws are necessary, they should be done with caution and through existing lines when possible to prevent trauma and bleeding complications.

Why Other Options Are Wrong

A. Set an automated blood pressure cuff for every 5 min

Frequent automatic cuff inflations can cause bruising and bleeding, especially on anticoagulated clients. Blood pressure should be monitored frequently but not at a rate that increases bleeding risk.

B. Administer IM morphine for pain as needed

IM injections are contraindicated for clients who have received thrombolytics due to the risk of bleeding into the muscle tissue. Pain medications should be given IV if needed.

C. Apply an ice pack to stop minor bleeding

Ice packs may help with vasoconstriction, but direct pressure is the first-line action for minor bleeding. Also, ice does not address systemic bleeding risk associated with thrombolytics.

Correct Answer B. Occupational Safety and Health Administration (OSHA)

Explanation

The Occupational Safety and Health Administration (OSHA) mandates that employers provide the hepatitis B vaccine to employees who are at risk for exposure to blood or other potentially infectious materials (such as nurses, lab techs, and other healthcare workers). This requirement is part of the Bloodborne Pathogens Standard, which aims to protect healthcare workers from infections.

Why Other Options Are Wrong

A. Health Insurance Portability and Accountability Act of 1996 (HIPAA)

HIPAA governs privacy and security of health information, not vaccination requirements or workplace safety protocols.

C. Professional standards review organization (PSRO)

PSROs are concerned with quality assurance and cost-effectiveness in healthcare delivery, not occupational health policies or vaccine protocols.

D. Emergency Medical Treatment and Active Labor Law (EMTALA)

EMTALA ensures emergency medical treatment is provided regardless of ability to pay, and does not relate to employee vaccination requirements.

Correct Answer C. Suction the infant's nares with a bulb syringe prior to feedings.

Explanation

Bronchiolitis, most commonly caused by respiratory syncytial virus (RSV), results in increased mucus production, nasal congestion, and difficulty breathing, especially in infants who are obligatory nose breathers. Suctioning the nares with a bulb syringe before feedings improves airway patency and reduces the risk of aspiration during feeding. This is a key supportive intervention in the care of infants with bronchiolitis.

Why Other Options Are Wrong

A. Apply oxygen via face mask if the infant's oxygen saturation level drops below 85%.

This threshold is too low. Oxygen should typically be administered if SpO₂ falls below 90–92%, especially in infants. Waiting until it reaches 85% increases the risk of hypoxia and complications.

B. Perform chest physiotherapy on the infant three times per day.

Chest physiotherapy is not recommended for bronchiolitis. It does not improve outcomes in infants with RSV-related illness and may actually cause discomfort or distress.

D. Initiate airborne precautions for the infant.

Bronchiolitis, especially when caused by RSV, requires contact and droplet precautions, not airborne precautions. Airborne precautions are used for illnesses like tuberculosis, measles, and varicella, which are transmitted via fine aerosolized particles.