a nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal t

ATI RN

ATI Fundamentals

1. 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?

A. Apply a vest restraint if self-extubation is attempted.
B. Monitor ventilator settings every 8 hours.
C. Document tube placement in centimeters at the angle of the jaw.
D. Assess breath sounds every 1 to 2 hours.

Correct answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

2. Which of the following substances increase the amount of urine produced?

A. Caffeine-containing drinks, such as coffee and cola
B. Beets
C. Urinary analgesics
D. Kaolin with pectin (Kaopectate)

Correct answer: A

Rationale: Caffeine is a diuretic, which means it increases urine production by promoting the excretion of water from the body through the kidneys. Therefore, substances like caffeine-containing drinks, such as coffee and cola, can lead to an increase in the amount of urine produced.

3. How many milliliters are equal to 20 cc?

A. 2
B. 20
C. 2000
D. 20000

Correct answer: B

Rationale: 1 cc (cubic centimeter) is equal to 1 ml. Therefore, 20 cc is equal to 20 ml. To convert between cubic centimeters (cc) and milliliters (ml), the values are equivalent since they both measure volume in the metric system. Choice A (2) is incorrect as it does not account for the direct conversion between cc and ml. Choice C (2000) and choice D (20000) are incorrect as they represent conversions based on a misunderstanding of the relationship between cc and ml.

4. 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.

5. A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy?

A. Teaching parenting skills to expectant mothers and their partners.
B. Conducting mental health screenings at the local community center
C. Referring clients with obesity to community exercise programs
D. Providing crisis intervention through a mobile counseling unit

Correct answer: A

Rationale: The correct answer is teaching parenting skills to expectant mothers and their partners. This intervention is a primary prevention strategy aimed at educating individuals before a problem or condition develops. By teaching parenting skills, the nurse is promoting healthy behaviors and relationships, which can prevent future issues. The other options involve secondary or tertiary prevention strategies by identifying and treating existing conditions or providing interventions after a problem has occurred.