ATI RN
Adult Medical Surgical ATI
1. A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?
- A. Provide respiratory support.
- B. Place the client in droplet isolation.
- C. Administer antihypertensive medications.
- D. Monitor ascites.
Correct answer: A
Rationale: In the late stage of inhalation anthrax, respiratory support is crucial due to the potential for respiratory failure. Providing oxygen therapy and maintaining airway patency are essential components of care to improve oxygenation and support respiratory function. Placing the client in droplet isolation is not necessary as inhalation anthrax is not transmitted from person to person through respiratory droplets. Administering antihypertensive medications is not indicated in the treatment of inhalation anthrax. Monitoring for ascites is not a priority in the late stage of inhalation anthrax.
2. A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?
- A. Initiating oxygen therapy
- B. Providing immediate rest for the client
- C. Positioning the client in high-Fowler's
- D. Administering a nebulized beta-adrenergic
Correct answer: D
Rationale: During an acute asthma exacerbation, the priority intervention is to administer a nebulized beta-adrenergic medication, such as albuterol, to help open the airways and improve breathing. This action helps address the underlying cause of the exacerbation. Oxygen therapy may be needed but is not the priority over administering the bronchodilator. Providing rest and positioning the client in high-Fowler's are important but come after administering the medication to address the immediate breathing difficulties.
3. A client reports a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions?
- A. Carbon monoxide poisoning
- B. Heat stroke
- C. Hypersensitivity reaction
- D. Oxygen toxicity
Correct answer: A
Rationale: When a client reports headache and vertigo after turning on the furnace for the first time, it suggests carbon monoxide poisoning. Carbon monoxide is an odorless, colorless gas that can be released by malfunctioning heating systems. Symptoms of carbon monoxide poisoning include headache, dizziness, weakness, nausea, and confusion. It is crucial for the nurse to suspect this condition promptly to ensure the client's safety and well-being.
4. A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
- A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
- B. Assess for an increase in temperature.
- C. Check the oximeter.
- D. Monitor for manifestations of increased intracranial pressure.
Correct answer: C
Rationale: When caring for a client who had an evacuation of a subdural hematoma, the nurse's priority is to check the oximeter. Monitoring oxygen saturation is crucial to ensure adequate tissue oxygenation, especially after such a procedure. This assessment helps in early detection of hypoxemia, which can be detrimental to the client's recovery. While observing for CSF leaks, assessing for temperature changes, and monitoring for signs of increased intracranial pressure are important, checking the oximeter takes precedence to address immediate oxygenation needs.
5. A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?
- A. "It might help if I tried sleeping only on my back."
- B. "I'll sleep better if I take a sleeping pill at night."
- C. "I'll get a humidifier to run at my bedside at night."
- D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
Correct answer: D
Rationale:
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