ATI RN
ATI Nursing Specialty
1. A nurse in a community health center is assessing the results of the purified protein derivative (PPD) testing she performed to screen for tuberculosis (TB). She interprets which of the following results as positive for a 6-year-old client with no risk factors for TB?
- A. 4-mm erythema
- B. 5-mm induration
- C. 10-mm wheal
- D. 15-mm induration
Correct answer: D
Rationale: The correct answer is D: 15-mm induration. In PPD testing, an induration (hardened raised area) of 15 mm or more is considered positive for TB in individuals with no risk factors. Choices A, B, and C are incorrect because an erythema of 4 mm, induration of 5 mm, or wheal of 10 mm are not indicative of a positive TB test result in a low-risk individual. Therefore, the interpretation of a 15-mm induration would lead the nurse to consider the test positive for TB in this case.
2. A client with peripheral arterial disease (PAD) is experiencing muscle pain or cramping during physical activity that resolves with rest. Which of the following symptoms is typically the initial reason clients with PAD seek medical attention?
- A. Intermittent claudication
- B. Dependent rubor
- C. Rest pain
- D. Foot ulcers
Correct answer: A
Rationale: The correct answer is Intermittent claudication. Intermittent claudication, which manifests as muscle pain or cramping during physical activity that improves with rest, is typically the initial reason clients with PAD seek medical attention. Dependent rubor, rest pain, and foot ulcers are more advanced symptoms of PAD and are not usually the initial reasons for seeking medical care.
3. When caring for a client with COPD, which intervention should the nurse include in the care plan?
- A. Restrict the client's fluid intake to less than 2 L/day.
- B. Encourage the client to use the upper chest for respiration.
- C. Have the client use the early-morning hours for exercise and activity.
- D. Instruct the client to use pursed-lip breathing.
Correct answer: D
Rationale: The correct answer is to instruct the client to use pursed-lip breathing. This technique helps improve breathing efficiency by keeping the airways open during exhalation and reducing air trapping. Restricting fluid intake to less than 2 L/day is not appropriate for a client with COPD, as they need adequate hydration. Using the upper chest for respiration is incorrect as it promotes shallow breathing, which is not ideal for COPD patients. While exercise is beneficial, early-morning hours may not be the best time for clients with COPD due to increased respiratory distress in the morning.
4. A client prescribed home oxygen therapy is receiving discharge teaching from a nurse. Which statement by the client indicates a need for further teaching?
- A. I will be able to tell the amount of oxygen being delivered by looking at the flowmeter.
- B. I should contact my doctor if I notice a decrease in my ability to concentrate.
- C. I will ensure that visitors smoke outside.
- D. I should see a frosty buildup on the tank when I refill my portable oxygen.
Correct answer: A
Rationale: The correct answer is A. The client's statement indicates a need for further teaching because the flowmeter indicates the flow rate of oxygen, not the total amount of oxygen being delivered. Choices B, C, and D demonstrate understanding of safety measures and indications for seeking medical attention in relation to home oxygen therapy, making them appropriate statements.
5. A nurse at a provider's office receives a phone call from a client who reports unrelieved chest pain after taking a nitroglycerin (Nitrostat) tablet 5 minutes ago. Which of the following is an appropriate response by the nurse?
- A. Tell the client to take an aspirin.
- B. Instruct the client to call 911.
- C. Have the client take another nitroglycerin tablet in 15 minutes.
- D. Advise the client to come to the office.
Correct answer: B
Rationale: In this scenario, the client reporting unrelieved chest pain after taking a nitroglycerin tablet could be indicative of a serious cardiac event. Instructing the client to call 911 is the most appropriate response because immediate medical attention is necessary for chest pain that is not relieved by nitroglycerin. Telling the client to take an aspirin (Choice A) may not address the urgency of the situation, and aspirin might not be appropriate depending on the client's medical history. Having the client take another nitroglycerin tablet (Choice C) without relief could lead to overdosage. Advising the client to come to the office (Choice D) is not the best course of action when dealing with a potential cardiac emergency that requires immediate intervention.
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