ATI RN
Adult Medical Surgical ATI
1. A client with asthma is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?
- A. Hypoglycemia
- B. Hypertension
- C. Polyuria
- D. Oral candidiasis
Correct answer: D
Rationale: Fluticasone is a corticosteroid often used to manage asthma. One of the common adverse effects associated with inhaled corticosteroids like fluticasone is oral candidiasis, also known as thrush. This fungal infection can develop in the mouth and throat due to the steroid's local immunosuppressive effects. Patients should be advised to rinse their mouths after using inhaled corticosteroids to reduce the risk of oral candidiasis. Monitoring for symptoms such as white patches, sore throat, or difficulty swallowing is essential to detect and manage this adverse effect promptly.
2. When performing tracheostomy care, which intervention should the nurse implement?
- A. Use aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply suction when inserting the catheter.
Correct answer: C
Rationale: When caring for a client with a tracheostomy, it is essential to ensure that the airway is maintained and secured at all times. Securing new tracheostomy ties before removing the old ones helps prevent accidental decannulation and ensures continuous airway patency. Aseptic technique is crucial to prevent infections but is not directly related to securing the tracheostomy ties. Cleaning the inner cannula with mild soap and water is important for maintaining hygiene but does not address the immediate need for securing the airway. Applying suction when inserting the catheter is not a standard practice during tracheostomy care.
3. A client is postoperative following an intermaxillary fixation due to multiple facial fractures. Which type of equipment should be at the client's bedside?
- A. Wire cutters
- B. NG tube
- C. Urinary catheter tray
- D. IV infusion pump
Correct answer: A
Rationale: In a client who has undergone intermaxillary fixation for facial fractures, wire cutters are essential equipment to have at the bedside in case of emergencies such as airway compromise. These wire cutters allow prompt removal of the wires securing the jaw if needed to ensure adequate airway patency. NG tube, urinary catheter tray, and IV infusion pump are important pieces of equipment in various clinical scenarios but are not specifically required for managing intermaxillary fixation postoperatively.
4. A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
- A. Poor impulse control
- B. Inability to discriminate words and letters
- C. Deficits in the right visual field
- D. Motor retardation
Correct answer: A
Rationale: A stroke affecting the right cerebral hemisphere can lead to poor impulse control due to the involvement of this area in regulating behavior and inhibiting impulses. Deficits in the right visual field are associated with stroke affecting the left cerebral hemisphere. Inability to discriminate words and letters may be seen in left cerebral hemisphere strokes. Motor retardation may be observed with strokes affecting motor areas in either hemisphere but is not the most specific finding related to a right cerebral hemisphere stroke.
5. Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?
- A. Position the head of the client's bed flat
- B. Turn the client every 4 hours
- C. Brush the client's teeth with a suction toothbrush every 12 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct answer: C
Rationale: Ventilator-associated pneumonia (VAP) is a common complication in clients receiving mechanical ventilation. Oral hygiene is crucial in reducing the risk of VAP. Brushing the client's teeth with a suction toothbrush every 12 hours helps prevent bacterial colonization in the oral cavity, which can be aspirated into the lungs. Positioning the head of the bed flat can increase the risk of aspiration. Turning the client every 4 hours is important for preventing pressure ulcers but not directly related to reducing VAP. Providing humidity in the ventilator tubing helps maintain airway moisture but does not directly address the risk of VAP.
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