ATI RN
ATI Fundamentals
1. A client has experienced a right-hemispheric stroke. Which of the following is not an expected finding?
- A. Impulse control difficulty
- B. Left hemiplegia
- C. Loss of depth perception
- D. Aphasia
Correct answer: D
Rationale: In a right-hemispheric stroke, the expected findings include left-sided hemiplegia (Choice B), loss of depth perception (Choice C), and impulse control difficulty (Choice A). Aphasia (Choice D) is typically associated with left-hemispheric strokes. Therefore, aphasia is not an expected finding in a client who has experienced a right-hemispheric stroke.
2. During an assessment, a healthcare provider observes a client with a chest tube and drainage system. What is an expected finding?
- A. Continuous bubbling in the water seal chamber
- B. Gentle constant bubbling in the suction control chamber
- C. Drainage system positioned upright at chest level
- D. Exposed sutures without dressing
Correct answer: B
Rationale: When assessing a client with a chest tube and drainage system, gentle constant bubbling in the suction control chamber is an expected finding. This indicates that the system is functioning properly. Continuous bubbling in the water seal chamber would suggest an air leak, the drainage system should be positioned upright at chest level to promote proper drainage, and exposed sutures without dressing would be an incorrect finding as they should be covered to prevent infection.
3. A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?
- A. Oxygen equipment
- B. Incentive spirometer
- C. Pulse oximeter
- D. Sterile dressing
Correct answer: B
Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.
4. When a chest tube is accidentally removed from a client, which of the following actions should the nurse NOT take first?
- A. Obtain a chest x-ray
- B. Apply sterile gauze to the insertion site
- C. Place tape around the insertion site
- D. Assess respiratory status
Correct answer: B
Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.
5. The client is receiving discharge teaching for a new prescription of phenelzine. The nurse should instruct the client that it is not safe to eat which of the following foods while taking this medication?
- A. whole grain bread
- B. Avocados
- C. Smoked salmon
- D. Pepperoni pizza
Correct answer: B
Rationale: Avocados contain high levels of tyramine, which can cause a hypertensive crisis when consumed with phenelzine, a monoamine oxidase inhibitor (MAOI). It is essential for clients taking MAOIs to avoid foods rich in tyramine to prevent dangerous interactions and potential health risks.
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