a nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury which of the
Logo

Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2023

1. A healthcare professional in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the healthcare professional take first?

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, airway compromise is a critical concern. Administering 100% humidified oxygen is the priority to ensure adequate oxygenation. This intervention takes precedence over obtaining baseline ECG, obtaining blood specimens, or inserting an IV catheter, as airway management and oxygenation are fundamental in the initial assessment and management of a client with potential airway compromise.

2. A client has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?

Correct answer: A

Rationale: Generalized petechiae and ecchymoses can indicate a potential issue with platelet function or count. Therefore, the most relevant laboratory test to evaluate this condition would be a platelet count. Platelet count helps assess the number of platelets in the blood, which are crucial for clotting and preventing bleeding. Monitoring platelet levels can provide important information about a client's bleeding risk and overall hematologic health.

3. The healthcare provider orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?

Correct answer: C

Rationale: To determine the flow rate in drops per minute, multiply the ordered volume per hour by the drop factor (100 ml/hour x 15 gtt/ml = 1500 gtt/hour). Then, divide the result by 60 minutes to convert it to drops per minute (1500 gtt/hour รท 60 minutes = 25 gtt/minute). Therefore, the correct answer is 25 gtt/minute.

4. A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:

Correct answer: A

Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.

5. A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?

Correct answer: B

Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.

Similar Questions

A healthcare provider is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?
When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?
A client with tuberculosis is receiving a new prescription for isoniazid (INH). The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?
A healthcare professional is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should NOT be included in the plan of care?
A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses