ATI RN
ATI Fundamentals Proctored Exam Quizlet
1. A healthcare professional is assessing a client who has a pulmonary embolism. Which of the following information should the healthcare professional not expect to find?
- A. Bradypnea
- B. Pleural friction rub
- C. Petechiae
- D. Tachycardia
Correct answer: A
Rationale: In a client with a pulmonary embolism, bradypnea, which is abnormally slow breathing, is not an expected finding. Pulmonary embolism typically presents with tachypnea (rapid breathing) due to the body's compensatory mechanism to increase oxygen levels. Pleural friction rub, petechiae, and tachycardia are commonly associated with a pulmonary embolism due to the impaired oxygenation and increased workload on the heart. Therefore, the healthcare professional should not expect to find bradypnea during the assessment of a client with a pulmonary embolism.
2. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?
- A. Notify the provider.
- B. Administer heparin via IV infusion.
- C. Administer oxygen therapy.
- D. Obtain a spiral CT scan.
Correct answer: C
Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.
3. When reviewing the prescriptions for a client with a pneumothorax, which of the following actions should the nurse perform first?
- A. Assess the client's pain.
- B. Obtain a large-bore IV needle for decompression.
- C. Administer lorazepam.
- D. Prepare for chest tube insertion.
Correct answer: B
Rationale: In a client with a pneumothorax, the priority action for the nurse is to obtain a large-bore IV needle for decompression. This intervention helps to relieve the pressure in the pleural space, allowing the lung to re-expand. Prompt decompression is crucial in managing a tension pneumothorax, which can be life-threatening. Assessing pain, administering medication, and preparing for chest tube insertion are important, but they should follow the immediate intervention of decompression in a critical situation like a tension pneumothorax.
4. A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?
- A. ''I am allergic to morphine.''
- B. ''I take antacids several times a day.''
- C. ''I had a blood clot in my leg several years ago.''
- D. ''It hurts to take a deep breath.''
Correct answer: B
Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.
5. A client with COPD expresses concerns about leaving the house due to continuous oxygen use. What is an appropriate response by the nurse?
- A. There are portable oxygen delivery systems that you can take with you.
- B. When you go out, you can remove the oxygen and then reapply it when you get home.
- C. You probably will not be able to go out as much as you used to.
- D. Home health services will come to see you so you will not need to get out.
Correct answer: A
Rationale: For a client with COPD concerned about leaving the house while on continuous oxygen, the nurse should provide reassurance by mentioning the availability of portable oxygen delivery systems. These systems allow the client to maintain their oxygen therapy while being mobile, enabling them to go out and engage in activities outside the home. This response promotes independence and quality of life for the client, addressing their immediate concerns and offering a practical solution to their perceived limitation.
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