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. When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
- A. Insert an oral airway
- B. Administer the abdominal thrust maneuver
- C. Turn the client to the side
- D. Perform a blind finger sweep
Correct answer: B
Rationale: When a client develops an airway obstruction and remains conscious, the nurse's initial action should be to administer the abdominal thrust maneuver. This technique, also known as the Heimlich maneuver, can help dislodge the obstructing object and clear the airway. Inserting an oral airway, turning the client to the side, or performing a blind finger sweep are not recommended as the first interventions for a conscious individual with an airway obstruction.
3. A client is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best?
- A. Ask the hospitals there about standard nurse-client ratios.
- B. Choose the hospital that has the newest technology.
- C. Find a hospital that is accredited by The Joint Commission.
- D. Use a facility affiliated with a medical or nursing school.
Correct answer: C
Rationale: Choosing a hospital accredited by The Joint Commission (TJC) or another accrediting body is the best advice as it ensures a focus on safety and quality standards.
4. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
- A. Urticaria
- B. Stridor
- C. Vomiting
- D. Hypotension
Correct answer: B
Rationale:
5. When preparing a client for transfer to the ICU for placement of a pulmonary artery catheter, the nurse should explain that this catheter is used to monitor which of the following conditions?
- A. Intracranial pressure
- B. Spinal cord perfusion
- C. Renal function
- D. Hemodynamic status
Correct answer: D
Rationale: A pulmonary artery catheter is primarily used to monitor hemodynamic status. It provides essential information on cardiac output, preload, afterload, and overall cardiovascular function. This data helps healthcare providers manage the client's fluid status, cardiac function, and guide treatment interventions in critically ill patients. Monitoring intracranial pressure, spinal cord perfusion, or renal function would require different monitoring devices and techniques, not a pulmonary artery catheter.
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