ATI RN
ATI Fundamentals
1. A healthcare provider is caring for a client following a thoracentesis. Which of the following manifestations should the healthcare provider NOT recognize as risks for complications?
- A. Dyspnea
- B. Localized bloody drainage on the dressing
- C. Fever
- D. Hypotension
Correct answer: B
Rationale: After a thoracentesis, some expected complications include dyspnea, fever, and hypotension. Localized bloody drainage on the dressing is a common and expected finding post-thoracentesis due to the procedure's nature of puncturing the chest wall. Therefore, the healthcare provider should not consider this finding as a risk for complications.
2. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?
- A. Less than 30 ml/hour
- B. 64 ml in 2 hours
- C. 90 ml in 3 hours
- D. 125 ml in 4 hours
Correct answer: A
Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.
3. What is required for effective hand washing?
- A. Soap or detergent to promote emulsification
- B. Hot water to destroy bacteria
- C. A disinfectant to increase surface tension
- D. All of the above
Correct answer: A
Rationale: To effectively wash hands, soap or detergent is essential as they help emulsify fats and oils, allowing them to be rinsed away. Hot water alone cannot effectively destroy bacteria, and a disinfectant is not typically required for routine hand washing.
4. A client is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take?
- A. Cleanse equipment before removal from the client's room.
- B. Limit the client's visitors to 30 minutes per day.
- C. Discard the client's linens in a double bag.
- D. Discard the radioactive source in a biohazard bag
Correct answer: D
Rationale: When caring for a client receiving brachytherapy, it is crucial to handle radioactive sources appropriately. Discarding the radioactive source in a biohazard bag is essential to prevent exposure to radiation. Cleaning equipment before removal, limiting client's visitors, or discarding linens in a double bag are not specific to the management of radioactive sources in brachytherapy.
5. Which natural body defense plays an active role in preventing infection?
- A. Yawning
- B. Body hair
- C. Hiccupping
- D. Rapid eye movements
Correct answer: B
Rationale: Body hair plays an active role in preventing infection by acting as a filter to block pathogens. It helps to prevent harmful substances from entering the body through the skin, providing a physical barrier against potential infections.
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