ATI RN
ATI RN Custom Exams Set 3
1. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?
- A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
- B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
- C. 56-year-old fourth hospital day after coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization
- D. 86-year-old; 48 hours postoperative repair of fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter
Correct answer: A
Rationale: The correct answer is A. This client situation presents with concerning clinical signs such as no urine output post kidney transplant, elevated temperature, tachycardia, hypotension, and restlessness, suggestive of acute renal failure and sepsis. These signs necessitate immediate intervention by the rapid response team (RRT) to address the potentially life-threatening conditions. Choice B is incorrect as the client is stable after chest tube removal and primarily anxious about going home. Choice C is incorrect as the client's symptoms are related to postoperative recovery and boredom, not indicating an urgent need for RRT consultation. Choice D is incorrect as the client post hip repair is stable, alert, and interacting normally, without signs of acute deterioration requiring RRT involvement.
2. Who took the position that organisms tend to repeat responses that lead to positive outcomes and tend not to repeat responses that lead to neutral or negative outcomes?
- A. Sigmund Freud
- B. B.F. Skinner
- C. Carl Rogers
- D. Abraham Maslow
Correct answer: B
Rationale: The correct answer is B.F. Skinner. Skinner proposed the theory of operant conditioning, where behavior is shaped by its consequences. Positive outcomes increase the likelihood of a behavior being repeated, while neutral or negative outcomes decrease it. Sigmund Freud (choice A) is known for his psychoanalytic theory, Carl Rogers (choice C) for person-centered therapy, and Abraham Maslow (choice D) for the hierarchy of needs.
3. A client in labor is receiving IV Opioid analgesics. Which of the following actions should the nurse take?
- A. Instruct the client to self-ambulate every 2 hours.
- B. Offer oral hygiene every 2 hours.
- C. Anticipate medication administration 2 hours prior to delivery.
- D. Monitor fetal heart rate every 2 hours.
Correct answer: B
Rationale: When a client is receiving IV Opioid analgesics during labor, the nurse should offer oral hygiene every 2 hours. Opioid analgesics can cause adverse effects like dry mouth, nausea, and vomiting. Providing oral hygiene care helps alleviate these symptoms and maintains the client's comfort and well-being during labor. Instructing the client to self-ambulate every 2 hours is not appropriate during labor as mobility may be limited. Anticipating medication administration 2 hours prior to delivery is not necessary as the timing of medication administration should be based on the client's needs and the progress of labor. Monitoring fetal heart rate every 2 hours is important during labor, but it is not specifically related to the client receiving IV Opioid analgesics.
4. Which intervention reduces reservoirs of infection in a healthcare setting?
- A. Placing capped needles and syringes in puncture-resistant containers
- B. Keeping bedside table surfaces clean and dry
- C. Changing dressings that become wet or soiled
- D. Placing tissues and soiled dressings in paper bags
Correct answer: A
Rationale: Placing capped needles and syringes in puncture-resistant containers is the correct intervention to reduce infection reservoirs in healthcare settings. This practice helps prevent accidental needle-stick injuries and contains potentially infectious materials properly. Keeping bedside table surfaces clean and dry (choice B) is essential for preventing the spread of infections but does not directly address reducing reservoirs of infection. Changing dressings that become wet or soiled (choice C) is important for wound care but does not specifically target infection reservoirs. Placing tissues and soiled dressings in paper bags (choice D) is a proper waste disposal practice but does not directly reduce reservoirs of infection in a healthcare setting.
5. What is the purpose of an escharotomy in burn management?
- A. To relieve pressure and improve circulation in burn injuries
- B. To remove necrotic tissue from a wound
- C. To prevent infection in burn injuries
- D. To remove excess fluid from burn wounds
Correct answer: A
Rationale: An escharotomy is performed to relieve pressure in areas affected by deep burns and improve circulation. This procedure involves making incisions through the eschar (burned and dead tissue) to release constricting tissue and allow for the return of blood flow. Choice B is incorrect because the removal of necrotic tissue is typically done through debridement, not escharotomy. Choice C is incorrect because preventing infection in burn injuries is usually achieved through proper wound care and antibiotic therapy, not escharotomy. Choice D is incorrect because removing excess fluid from burn wounds is managed through methods like fluid resuscitation and monitoring, not escharotomy.