ATI RN
ATI Fundamentals
1. 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.
2. When is additional Vitamin C not required?
- A. Infancy
- B. Young adulthood
- C. Childhood
- D. Pregnancy
Correct answer: B
Rationale: Vitamin C requirements are increased during infancy, childhood, and pregnancy due to growth and development. However, during young adulthood, the body generally requires a consistent amount of Vitamin C as it is not undergoing rapid growth or physiological changes that necessitate an increase in Vitamin C intake.
3. A client has chronic pancreatitis. Which of the following dietary recommendations should be made?
- A. Coffee with creamer
- B. Lettuce with sliced avocados
- C. Broiled skinless chicken breast with brown rice
- D. None of the above
Correct answer: C
Rationale: Chronic pancreatitis requires a low-fat diet to reduce stress on the pancreas. Broiled skinless chicken breast with brown rice is a suitable option as it is low in fat. Coffee with creamer and lettuce with sliced avocados are not recommended for individuals with chronic pancreatitis due to their fat content. Choosing options high in fat can exacerbate symptoms and increase the workload on the pancreas, worsening the condition.
4. A client with vision loss is under the care of a nurse. Which of the following actions should the nurse AVOID?
- A. Keep objects in the client's room in the same place
- B. Ensure there is high-wattage lighting in the client's room
- C. Approach the client from the side
- D. Allow extra time for the client to perform tasks
Correct answer: C
Rationale: Approaching a client with vision loss from the side can startle them and may lead to accidents or discomfort. It is important to approach them from the front so they are aware of your presence. Keeping objects in the same place aids in familiarity and reduces the risk of falls. High-wattage lighting enhances visibility for the client. Allowing extra time for tasks accommodates the client's potential slower pace and ensures they can perform tasks safely.
5. A client reports that the medication the nurse is administering appears different than what they take at home. Which of the following responses should the nurse take?
- A. Did the doctor discuss with you that there was a change in this medication?
- B. I recommend that you take this medication as prescribed
- C. Do you know why this medication is being prescribed to you?
- D. I will call the pharmacist now to check on this medication
Correct answer: A
Rationale: When a client reports that the medication appears different than what they take at home, it is crucial for the nurse to ensure the safety and accuracy of the medication being administered. The most appropriate action for the nurse to take in this situation is to call the pharmacist to verify the medication, dosage, and any potential changes. This proactive step helps prevent medication errors and ensures the client's safety and well-being.
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