ATI RN
ATI Fundamentals
1. When assessing a client with sinusitis, which technique should the nurse use to identify manifestations of this disorder?
- A. Percussion of the frontal sinuses
- B. Auscultation of the trachea
- C. Inspection of the nasal mucosa
- D. Palpation of the orbital areas
Correct answer: D
Rationale: Sinusitis is an inflammation of the sinus cavities, which can cause tenderness and pain around the eyes (orbital areas). Palpation of the orbital areas can help identify tenderness and swelling associated with sinusitis. Auscultation of the trachea and percussion of the frontal sinuses are not relevant assessment techniques for sinusitis. Inspection of the nasal mucosa may reveal signs of inflammation, but palpation of the orbital areas is a more direct method to assess for tenderness and swelling in this specific condition.
2. A healthcare professional is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the healthcare professional NOT expect to be at risk?
- A. Client who has dysphagia
- B. Client who has AIDS
- C. Client who was vaccinated for pneumococcus and influenza 6 months ago
- D. Client who has a closed head injury and is receiving ventilation
Correct answer: C
Rationale: A client who was vaccinated for pneumococcus and influenza 6 months ago would have a reduced risk of developing pneumonia compared to those who have not been vaccinated. Vaccination helps protect individuals from specific pathogens, thereby lowering the risk of infection. Clients with dysphagia, AIDS, or a closed head injury and receiving ventilation are at higher risk for pneumonia due to compromised immunity, respiratory function, or protective airway reflexes, respectively.
3. A healthcare professional is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
- A. Impulse control difficulty
- B. Poor judgement
- C. Inability to recognize familiar objects
- D. Loss of depth perception
Correct answer: C
Rationale: Patients who have experienced a left-hemispheric stroke may exhibit symptoms of agnosia, which is the inability to recognize familiar objects or people. This occurs due to damage to the right hemisphere of the brain, which is responsible for visual and spatial perception. Impulse control difficulty, poor judgment, and loss of depth perception are not typically associated with left-hemispheric strokes.
4. A healthcare professional is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the healthcare professional NOT include in the plan of care?
- A. Have suction equipment available for use
- B. Feed the client thickened liquids
- C. Place food on the unaffected side of the client's mouth
- D. Assign an assistive personnel to feed the client slowly
Correct answer: D
Rationale: When caring for a client with dysphagia, it is crucial to ensure safe feeding practices. Assigning an assistive personnel to feed the client slowly may not be appropriate as it can increase the risk of aspiration. Thickened liquids, having suction equipment available, and placing food on the unaffected side of the mouth are all appropriate measures to support a client with dysphagia in safe eating and drinking.
5. During the removal of a chest tube, what should the nurse instruct the client to do?
- A. Lie on their left side.
- B. Use the incentive spirometer.
- C. Cough at regular intervals.
- D. Perform the Valsalva maneuver.
Correct answer: D
Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.
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