ATI RN
ATI Nursing Specialty
1. A provider is discharging a client with a prescription for home oxygen therapy. Client and family teaching by the nurse should include all of the following instructions except?
- A. Cleanse the mask or collar with soapy water every other day.
- B. Ensure that the straps on the mask are secure but not too tight.
- C. Apply petroleum jelly around and inside the nares.
- D. Post 'no smoking' warning signs at home in a prominent location.
Correct answer: C
Rationale: When providing instructions for home oxygen therapy, it is important to ensure safety and proper care. Choices A, B, and D are all essential instructions for the client and family. Choice C, 'Apply petroleum jelly around and inside the nares,' is incorrect. Petroleum jelly should not be used near oxygen sources as it is flammable and can increase the risk of fire hazard. Therefore, this instruction should not be included in the teaching.
2. A client with chronic obstructive pulmonary disease (COPD expresses difficulty in bringing up bronchial secretions. Which action should the nurse take to help the client with tenacious bronchial secretions?
- A. Maintaining a semi-Fowler's position as much as possible
- B. Administering oxygen via nasal cannula at 2 L per min
- C. Helping the client select a low-salt diet
- D. Encouraging the client to drink eight glasses of water daily
Correct answer: D
Rationale: Encouraging the client to drink eight glasses of water daily is the most appropriate action to help with tenacious bronchial secretions in COPD. Increased fluid intake can help in thinning the mucus, making it easier for the client to cough up and clear secretions. This addresses the client's difficulty in bringing up bronchial secretions. Maintaining a semi-Fowler's position can aid in breathing but does not directly address the issue of clearing secretions. Administering oxygen may be necessary for COPD, but it does not specifically target the tenacious secretions. Selecting a low-salt diet can be helpful in managing COPD in general, but it does not directly address the client's current concern of clearing bronchial secretions.
3. A client is receiving oxygen therapy via a nasal cannula. The nurse should explain that this method of oxygen delivery does which of the following?
- A. Delivers a specific concentration of oxygen constantly
- B. Delivers a high concentration of oxygen
- C. Delivers a low concentration of oxygen
- D. Restricts the client's ability to eat, speak, or drink
Correct answer: A
Rationale: A nasal cannula is a device used for delivering supplemental oxygen to patients. It delivers a specific concentration of oxygen constantly, typically ranging from 1-6 liters per minute. This method is effective for patients who require low to moderate levels of oxygen. Choices B and C are incorrect because a nasal cannula does not deliver a high concentration of oxygen and is not considered a low concentration delivery method. Choice D is incorrect because a nasal cannula does not restrict the client's ability to eat, speak, or drink; it allows them to perform these activities while receiving oxygen therapy.
4. A nurse is preparing for the hospital admission of a client who is suspected to have active tuberculosis (TB). Which of the following precautions should the nurse plan to implement to safely care for this client?
- A. Staff and visitors should wear gowns, masks, and gloves while in the client's room.
- B. The client should be placed in a private room with a special ventilation system.
- C. The client may be placed in a room with other clients who require droplet isolation precautions.
- D. The protocol for donning and removing personal protective equipment before entering or leaving the room of a client with TB is different than for clients who are in other types of isolation.
Correct answer: B
Rationale: When caring for a client suspected of having active tuberculosis (TB), it is essential to place the client in a private room with a special ventilation system to prevent the spread of TB bacteria to others. Choice A is incorrect because staff and visitors should wear respiratory protection, not just gowns, masks, and gloves. Choice C is incorrect as clients with TB should not be placed in a room with other clients, as they need to be isolated to prevent transmission. Choice D is incorrect because the protocol for donning and removing personal protective equipment for clients with TB is similar to other types of isolation, focusing on proper infection control measures.
5. A client is telling the nurse in the clinic that he gets a headache after taking sublingual nitroglycerin (Nitrostat) for his angina pain. Which of the following should the nurse instruct the client to do?
- A. Reduce the nitroglycerin dose
- B. Ask the provider to prescribe a strong analgesic
- C. Lie down in a cool environment and rest
- D. Ask the provider to prescribe a different medication
Correct answer: C
Rationale: The correct answer is to instruct the client to lie down in a cool environment and rest after taking sublingual nitroglycerin for angina pain. Headaches are a common side effect of nitroglycerin due to its vasodilatory effects, and resting in a cool environment can help alleviate the headache. Reducing the nitroglycerin dose is not recommended without consulting the healthcare provider as it may compromise the effectiveness of the medication in managing angina. Asking for a strong analgesic is not appropriate since the headache is likely related to the nitroglycerin and not a separate issue requiring a pain reliever. Requesting a different medication should also involve consulting the healthcare provider to ensure an appropriate alternative is prescribed for angina management.
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