ATI RN
ATI Fundamentals
1. A client in the emergency department is experiencing an acute asthma attack. Which assessment indicates an improvement in respiratory status?
- A. SaO2 95%
- B. Wheezing
- C. Retraction of sternal muscles
- D. Premature ventricular complexes (PVC's)
Correct answer: A
Rationale: An SaO2 of 95% indicates an improvement in the client's oxygen saturation, suggesting better respiratory status. In asthma exacerbation, a decrease in SaO2 levels would signal worsening respiratory distress. Wheezing, retraction of sternal muscles, and premature ventricular complexes are indicators of respiratory compromise and worsening respiratory status in acute asthma attacks. Monitoring SaO2 levels is crucial in assessing the effectiveness of interventions and guiding treatment decisions.
2. A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
- A. Apply a vest restraint if self-extubation is attempted.
- B. Monitor ventilator settings every 8 hours.
- C. Document tube placement in centimeters at the angle of the jaw.
- D. Assess breath sounds every 1 to 2 hours.
Correct answer: D
Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.
3. During the removal of a chest tube, what should the nurse instruct the client to do?
- A. Lie on their left side.
- B. Use the incentive spirometer.
- C. Cough at regular intervals.
- D. Perform the Valsalva maneuver.
Correct answer: D
Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.
4. Which deficiency is most commonly seen in individuals with alcohol use disorder?
- A. Thiamine
- B. Riboflavin
- C. Pyridoxine
- D. Pantothenic acid
Correct answer: A
Rationale: Thiamine deficiency, also known as Vitamin B1 deficiency, is the most common vitamin deficiency seen in individuals with alcohol use disorder. Chronic alcohol consumption can lead to decreased thiamine absorption and utilization, as well as poor dietary intake. Thiamine deficiency can result in serious neurological complications, such as Wernicke-Korsakoff syndrome, making it essential to address thiamine supplementation in individuals with alcohol use disorder.
5. Which of the following parameters should be checked when assessing respirations?
- A. Rate
- B. Rhythm
- C. Symmetry
- D. All of the above
Correct answer: D
Rationale: When assessing respirations, it is essential to evaluate the rate at which breaths are taken, the rhythm of breathing patterns, and the symmetry of chest expansion. Each of these parameters provides valuable information about a person's respiratory status. Therefore, it is important to assess all of the listed parameters to have a comprehensive understanding of the individual's respiratory function.
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