ATI RN
Adult Medical Surgical ATI
1. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?
- A. Raise the affected extremity above the level of the heart.
- B. Immobilize the affected extremity with a splint
- C. Apply ice to the bite area
- D. Apply a tourniquet to the affected extremity.
Correct answer: B
Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.
2. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
- A. African American churches
- B. Asian American groceries
- C. High school sports camps
- D. Women's health clinics
Correct answer: A
Rationale: The correct answer is African American churches. African Americans in the United States have one of the highest rates of hypertension globally. By providing services at African American churches, the nurse can effectively reach this priority population. While hypertension education and screening are essential for all groups, African Americans are the priority population for this intervention due to their disproportionately high rates of hypertension.
3. A client with COPD is developing a plan of care. Which of the following interventions should the nurse include in the plan?
- A. Restrict the client's fluid intake to less than 2 L/day
- B. Provide the client with a low-protein diet
- C. Have the client use the early-morning hours for exercise and activity
- D. Instruct the client to use pursed-lip breathing
Correct answer: D
Rationale: In COPD, pursed-lip breathing helps improve breathing efficiency by maintaining positive pressure in the airways, preventing airway collapse, and promoting oxygenation. This technique assists in controlling respiratory rate, reducing dyspnea, and enhancing oxygen saturation levels. Restricting fluid intake is not typically a part of COPD management. Providing a low-protein diet is not a standard intervention for COPD. Early-morning hours are generally not recommended for exercise due to cooler temperatures and higher pollution levels, which can exacerbate COPD symptoms.
4. A client is prescribed albuterol (Proventil) via a metered-dose inhaler. Which action should the nurse take to ensure effective use of this medication?
- A. Instruct the client to inhale quickly while administering the medication.
- B. Have the client hold their breath for 10 seconds after inhaling the medication.
- C. Tell the client to exhale immediately after inhaling the medication.
- D. Encourage the client to use the inhaler as needed only when experiencing symptoms.
Correct answer: B
Rationale: To ensure effective use of albuterol via a metered-dose inhaler, the nurse should have the client hold their breath for 10 seconds after inhaling the medication. This action allows the medication to reach deeper into the airways. Inhaling slowly and deeply, not quickly, is recommended for optimal drug delivery. Exhaling immediately after inhaling the medication would expel it before it can take effect. It's essential for the client to follow the prescribed regimen of medication usage, not just using the inhaler when symptoms are present.
5. When caring for a client with acute renal failure, which laboratory value is most important to monitor?
- A. Serum sodium
- B. Serum potassium
- C. Serum calcium
- D. Serum chloride
Correct answer: B
Rationale: In acute renal failure, monitoring serum potassium is crucial because impaired kidney function can lead to hyperkalemia, which can result in life-threatening cardiac dysrhythmias. Elevated potassium levels need close monitoring and prompt interventions to prevent serious complications.
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