ATI RN
Adult Medical Surgical ATI
1. 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.
2. 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.
3. A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?
- A. Provide respiratory support.
- B. Place the client in droplet isolation.
- C. Administer antihypertensive medications.
- D. Monitor ascites.
Correct answer: A
Rationale: In the late stage of inhalation anthrax, respiratory support is crucial due to the potential for respiratory failure. Providing oxygen therapy and maintaining airway patency are essential components of care to improve oxygenation and support respiratory function. Placing the client in droplet isolation is not necessary as inhalation anthrax is not transmitted from person to person through respiratory droplets. Administering antihypertensive medications is not indicated in the treatment of inhalation anthrax. Monitoring for ascites is not a priority in the late stage of inhalation anthrax.
4. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?
- A. Raise the affected extremity above the level of the heart.
- B. Immobilize the affected extremity with a splint
- C. Apply ice to the bite area
- D. Apply a tourniquet to the affected extremity.
Correct answer: B
Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.
5. A client had a total hip arthroplasty. Which of the following prescriptions should the nurse verify with the provider?
- A. Administer enoxaparin 30 mg subcutaneously every 12 hr
- B. Place a wedge or pillow between the client's legs when turning.
- C. Instruct the client to restrict flexion of the hip past 120�.
- D. Encourage the client to perform foot and calf exercises every 2 hr
Correct answer: C
Rationale: Following a total hip arthroplasty, the client should be instructed to restrict hip flexion past 90 degrees to prevent dislocation of the prosthesis. Restricting flexion past 120 degrees is excessive and could lead to complications. Therefore, the nurse should verify this prescription with the provider to ensure the client's safety and proper postoperative care.
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