ATI RN
Adult Medical Surgical ATI
1. 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.
2. 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.
3. When teaching a client with chronic obstructive pulmonary disease who will start using fluticasone via MDI twice daily, which instruction should the nurse include?
- A. Monitor your heart rate before each dose.
- B. Inspect your mouth for lesions daily.
- C. Do not use this medication to relieve an acute attack.
- D. Do not skip the morning dose even if symptom-free.
Correct answer: B
Rationale: It is crucial for clients using inhaled corticosteroids like fluticasone to inspect their mouths daily for signs of oral thrush, a common side effect. Checking the mouth can help identify lesions early, allowing for timely intervention to prevent worsening of the condition. Monitoring heart rate is not specifically required for this medication. Fluticasone is a maintenance medication used to manage COPD, not to relieve acute attacks. Skipping doses, especially in the morning, can lead to inadequate control of COPD symptoms.
4. 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.
5. A healthcare provider is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the provider place at the client's bedside?
- A. Bag valve mask device
- B. Defibrillator machine
- C. Chest tube equipment
- D. Central venous catheter tray
Correct answer: A
Rationale: When a client receives a competitive neuromuscular blocking agent, it can lead to respiratory muscle paralysis. Placing a bag valve mask device at the client's bedside is crucial for providing immediate respiratory support in case of respiratory depression or failure. This device allows manual ventilation by squeezing the bag to deliver breaths to the client. The other options, such as a defibrillator machine, chest tube equipment, and central venous catheter tray, are not directly related to managing respiratory complications associated with neuromuscular blockade.
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