ATI RN
ATI Fundamentals
1. While caring for a client in a clinic, a healthcare professional learns that the client woke up not recognizing their partner, surroundings, has chills, and chest pain worsening upon inspiration. What should be the healthcare professional's priority action?
- A. Obtain baseline vital signs and oxygen saturation.
- B. Obtain a sputum culture.
- C. Obtain a complete history from the client.
- D. Provide a pneumococcal vaccine.
Correct answer: A
Rationale: The priority action for the healthcare professional is to obtain the client's baseline vital signs and oxygen saturation. This will provide essential information on the client's current physiological status and help guide further assessment and intervention. Assessing the vital signs and oxygen saturation can help identify any immediate concerns like hypoxia or sepsis, which require prompt attention. While obtaining a complete history and considering a pneumococcal vaccine may be important in the overall care of the client, assessing the vital signs and oxygen saturation takes precedence to address the client's immediate physiological needs.
2. During the removal of a chest tube, what should the nurse instruct the client to do?
- A. Lie on their left side.
- B. Use the incentive spirometer.
- C. Cough at regular intervals.
- D. Perform the Valsalva maneuver.
Correct answer: D
Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.
3. Prior to a thoracentesis, which of the following actions should the nurse take?
- A. Position the client in an upright position, leaning over the bedside table.
- B. Explain the procedure.
- C. Obtain ABGs.
- D. Administer benzocaine spray.
Correct answer: A
Rationale: Positioning the client in an upright position, leaning over the bedside table helps to facilitate access to the thoracic cavity during the thoracentesis procedure. This position allows for easier identification and access to the insertion site. Explaining the procedure to the client is important, but positioning is the priority. Obtaining ABGs is not directly related to the thoracentesis procedure. Administering benzocaine spray is not a standard practice before a thoracentesis.
4. A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?
- A. Oxygen equipment
- B. Incentive spirometer
- C. Pulse oximeter
- D. Sterile dressing
Correct answer: B
Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.
5. When assessing a client with sinusitis, which technique should the nurse use to identify manifestations of this disorder?
- A. Percussion of the frontal sinuses
- B. Auscultation of the trachea
- C. Inspection of the nasal mucosa
- D. Palpation of the orbital areas
Correct answer: D
Rationale: Sinusitis is an inflammation of the sinus cavities, which can cause tenderness and pain around the eyes (orbital areas). Palpation of the orbital areas can help identify tenderness and swelling associated with sinusitis. Auscultation of the trachea and percussion of the frontal sinuses are not relevant assessment techniques for sinusitis. Inspection of the nasal mucosa may reveal signs of inflammation, but palpation of the orbital areas is a more direct method to assess for tenderness and swelling in this specific condition.
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