ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A client has a right-sided pneumothorax, and a chest tube is inserted. Which finding indicates that the chest drainage system is functioning correctly?
- A. Gentle bubbling in the suction chamber
- B. Crepitus around the insertion site
- C. Constant bubbling in the water seal chamber
- D. Absence of breath sounds on the right side
Correct answer: A
Rationale: In a chest drainage system, gentle bubbling in the suction chamber indicates proper functioning, showing that the system is connected and working effectively to remove air or fluid from the pleural space. Crepitus around the insertion site (Choice B) suggests subcutaneous emphysema, not chest tube functionality. Constant bubbling in the water seal chamber (Choice C) indicates an air leak. Absence of breath sounds on the right side (Choice D) is indicative of the pneumothorax, not the chest tube function.
2. A client has a new prescription for Enoxaparin. Which of the following instructions should the nurse include?
- A. Massage the injection site after administration.
- B. Aspirate before injecting the medication.
- C. Administer the medication into the abdomen.
- D. Administer the medication via intramuscular injection.
Correct answer: C
Rationale: The correct answer is to administer the medication into the abdomen. Enoxaparin is a medication that is administered subcutaneously, typically in the abdomen to ensure proper absorption. Massaging the injection site should be avoided as it can lead to bruising or bleeding under the skin. Aspirating before injecting the medication is not necessary for subcutaneous injections like Enoxaparin. Administering the medication via intramuscular injection is incorrect as Enoxaparin should be given subcutaneously.
3. An RN cared for a state senator during the day shift. Later that day he was having dinner with friends when the news mentioned the senator had been hospitalized. The RN�s friends asked if he knew what was wrong with the senator. Which ethical principle should the RN consider when replying?
- A. Fidelity
- B. Confidentiality
- C. Veracity
- D. Accountability
Correct answer: B
Rationale: The principle of confidentiality requires nurses to hold healthcare information and anything patients tell them in the strictest confidence.
4. Which statement best reflects the role of the therapeutic relationship in fostering positive behaviors in children?
- A. It may be used as an intervention strategy to help a child with positive behaviors
- B. The relationship with parents or teachers is more important
- C. It is not essential for the child's behaviors
- D. Children will not pay attention to the therapist
Correct answer: A
Rationale: A strong therapeutic relationship can significantly influence the development of positive behaviors in children. When a child feels connected, understood, and supported by a therapist, it can lead to better outcomes in promoting positive behaviors and emotional well-being.
5. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?
- A. Check the client's identification band
- B. Verify the provider's prescription
- C. Prime the IV tubing with 0.9% sodium chloride
- D. Obtain the client's vital signs
Correct answer: A
Rationale: The correct first action for the nurse to take when preparing to administer a unit of packed RBCs is to check the client's identification band. This step is crucial to ensure that the correct blood is administered to the right client, preventing any errors or adverse reactions. Verifying the provider's prescription, priming the IV tubing, and obtaining the client's vital signs are important steps in the process but should follow the initial identification check to prioritize patient safety.
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