ATI RN
ATI RN Adult Medical Surgical Online Practice 2023 A
1. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
- A. Urticaria
- B. Stridor
- C. Vomiting
- D. Hypotension
Correct answer: B
Rationale:
2. A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?
- A. Initiating oxygen therapy
- B. Providing immediate rest for the client
- C. Positioning the client in high-Fowler's
- D. Administering a nebulized beta-adrenergic
Correct answer: D
Rationale: During an acute asthma exacerbation, the priority intervention is to administer a nebulized beta-adrenergic medication, such as albuterol, to help open the airways and improve breathing. This action helps address the underlying cause of the exacerbation. Oxygen therapy may be needed but is not the priority over administering the bronchodilator. Providing rest and positioning the client in high-Fowler's are important but come after administering the medication to address the immediate breathing difficulties.
3. A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
- A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
- B. Assess for an increase in temperature.
- C. Check the oximeter.
- D. Monitor for manifestations of increased intracranial pressure.
Correct answer: C
Rationale: When caring for a client who had an evacuation of a subdural hematoma, the nurse's priority is to check the oximeter. Monitoring oxygen saturation is crucial to ensure adequate tissue oxygenation, especially after such a procedure. This assessment helps in early detection of hypoxemia, which can be detrimental to the client's recovery. While observing for CSF leaks, assessing for temperature changes, and monitoring for signs of increased intracranial pressure are important, checking the oximeter takes precedence to address immediate oxygenation needs.
4. Prior to performing percussion, vibration, and postural drainage on an adolescent client with pneumonia, which of the following nursing actions should the nurse complete first?
- A. Auscultate lung fields
- B. Assess pulse and respirations
- C. Assess characteristics of the sputum
- D. Instruct the client to slowly exhale with pursed lips
Correct answer: A
Rationale: Before initiating percussion, vibration, and postural drainage, the nurse should first auscultate the lung fields to assess the baseline lung sounds and identify areas of congestion or abnormality. This initial assessment helps the nurse to tailor the percussion and drainage techniques effectively. Assessing pulse and respirations, sputum characteristics, and providing instructions to the client for exhalation are important steps in the procedure but should follow the initial auscultation to ensure a comprehensive and individualized care approach.
5. When reviewing the provider's orders, a nurse recognizes that clarification is needed for which of the following medications in a client experiencing an exacerbation of asthma?
- A. Propranolol
- B. Theophylline
- C. Montelukast
- D. Prednisone
Correct answer: A
Rationale: The correct answer is Propranolol. Propranolol is a beta-blocker that can potentially exacerbate asthma symptoms due to its mechanism of action. It can cause bronchoconstriction, which is harmful for a client experiencing an asthma exacerbation. Theophylline, Montelukast, and Prednisone are commonly used in the treatment of asthma exacerbations and would not typically require clarification in this context.
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