ATI RN
Nutrition ATI Test
1. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?
- A. Instruct the client to observe strict bed rest
- B. Check for epidural catheter drainage
- C. Administer analgesia through the epidural catheter as prescribed
- D. Assess respiratory rate carefully
Correct answer: D
Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.
2. Which of the four phases of emergency management is defined as 'sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects'?
- A. Recovery
- B. Mitigation
- C. Response
- D. Preparedness
Correct answer: B
Rationale: The correct answer is B, 'Mitigation.' Mitigation is the phase of emergency management that focuses on sustained actions aimed at reducing or eliminating long-term risks to people and property from natural hazards. Recovery (A) involves restoring and rebuilding infrastructure, housing, and services after a disaster. Response (C) deals with immediate actions taken to save lives and prevent further damage during a disaster. Preparedness (D) involves planning, training, and equipping organizations and communities to effectively respond to emergencies.
3. The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:
- A. Narrowing of the pulse pressure
- B. Vomiting
- C. Periorbital edema
- D. A positive Kernig's sign
Correct answer: C
Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.
4. In the management process, the periodic checking of the results of action to make sure that it coincides with the goal of the institution is termed as:
- A. Planning
- B. Evaluating
- C. Directing
- D. Organizing
Correct answer: B
Rationale: The correct answer is B: Evaluating. Evaluating involves the periodic checking of results to ensure they align with the institution's goals. Planning (choice A) is about setting goals and determining the actions required to achieve them. Directing (choice C) involves overseeing and guiding the activities of individuals or teams to accomplish goals. Organizing (choice D) is about arranging resources and tasks to achieve objectives. In the context of the management process described, evaluating best fits the action of checking results against goals.
5. In an extreme situation and when no other resident or intern is available, should a nurse receive telephone orders, the order has to be correctly written and signed by the physician within:
- A. 24 hours
- B. 36 hours
- C. 48 hours
- D. 12 hours
Correct answer: B
Rationale: In an extreme situation where no other resident or intern is available, if a nurse receives telephone orders, the order has to be correctly written and signed by the physician within 36 hours. This time frame ensures timely documentation and validation of the orders. Choice A (24 hours) is too short a period for busy physicians to fulfill the task. Choice C (48 hours) is too long and delays the incorporation of physician orders into the patient's care plan. Choice D (12 hours) may not provide enough time for the physician to review and sign the order, especially in situations where immediate attention is not required.
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