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 client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid exposure to sunlight while taking this medication.
- C. Report any numbness or tingling in extremities.
- D. Have liver function tests done regularly.
Correct answer: D
Rationale: Regular monitoring of liver function tests is crucial for clients taking isoniazid (INH) due to the potential risk of hepatotoxicity. Isoniazid can cause liver damage, and early detection through routine liver function tests can help prevent severe complications.
3. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?
- A. Since many of your family members are carriers, your children will also be carriers of the gene.
- B. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.
- C. Since you have a family history of cystic fibrosis, I would encourage you & your partner to be tested.
- D. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.
Correct answer: C
Rationale: Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client & partner to be tested for the abnormal gene. The other statements are not true.
4. A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?
- A. Average daily fluid intake
- B. Neck circumference
- C. Height & weight
- D. Occupation & hobbies
Correct answer: D
Rationale: Obtaining information about a client's occupation and hobbies is crucial when assessing respiratory status as many respiratory problems can result from chronic exposure to inhalation irritants related to these activities. Understanding the client's potential exposure can help the healthcare professional identify risk factors and provide appropriate interventions to promote respiratory health.
5. A client with emphysema is being cared for by a nurse. Which of the following findings should the nurse not expect to assess in this client?
- A. Dyspnea
- B. Bradycardia
- C. Barrel chest
- D. Clubbing of the fingers
Correct answer: B
Rationale: Emphysema is a chronic lung condition characterized by shortness of breath (dyspnea), a barrel-shaped chest due to hyperinflation of the lungs (barrel chest), and clubbing of the fingers (enlargement of fingertips). Bradycardia (slow heart rate) is not typically associated with emphysema. In emphysema, the primary focus is on respiratory complications rather than cardiac issues.
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