ATI RN
Adult Medical Surgical ATI
1. 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.
2. 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: When a client is vomiting, the priority action for the nurse is to prevent the client from aspirating. Aspiration can lead to serious respiratory complications. Providing the client with an emesis basin can be helpful but preventing aspiration takes precedence. Notifying housekeeping and administering an antiemetic are secondary actions that can be addressed once the client's safety is ensured.
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 has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?
- A. Continue to monitor the client.
- B. Immediately notify the healthcare provider.
- C. Reposition the client to the left side.
- D. Clamp the chest tube near the water seal.
Correct answer: A
Rationale: In a client with a three-chamber closed chest tube system, a rise in the water seal chamber with client inspiration is an expected finding. The nurse should continue to monitor the client as this indicates that the system is functioning correctly. There is no need to notify the healthcare provider, reposition the client, or clamp the chest tube as these actions are not indicated in response to a rise in the water seal chamber.
5. A client with tuberculosis is starting medication therapy with isoniazid, rifampin, and pyrazinamide. Which of the following instructions should the nurse include?
- A. Take isoniazid with an antacid.
- B. Provide a sputum specimen every 2 weeks to the clinic for testing.
- C. Expect your sputum cultures to be negative after 6 months of therapy.
- D. Drink at least 8 ounces of water when you take the pyrazinamide tablet.
Correct answer: D
Rationale: Pyrazinamide can cause gastrointestinal upset and is best taken with a full glass of water to minimize irritation to the stomach lining. This instruction helps reduce the risk of adverse effects associated with pyrazinamide. Options A and C are not directly related to the medication regimen for tuberculosis. While sputum testing is important, the frequency mentioned in option B is not required every two weeks.
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