ATI RN
Adult Medical Surgical ATI
1. When performing tracheostomy care, which intervention should the nurse implement?
- A. Use aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply suction when inserting the catheter.
Correct answer: C
Rationale: When caring for a client with a tracheostomy, it is essential to ensure that the airway is maintained and secured at all times. Securing new tracheostomy ties before removing the old ones helps prevent accidental decannulation and ensures continuous airway patency. Aseptic technique is crucial to prevent infections but is not directly related to securing the tracheostomy ties. Cleaning the inner cannula with mild soap and water is important for maintaining hygiene but does not address the immediate need for securing the airway. Applying suction when inserting the catheter is not a standard practice during tracheostomy care.
2. During an admission assessment of a client with COPD and emphysema complaining of a frequent productive cough and shortness of breath, what assessment finding should the nurse anticipate?
- A. Respiratory alkalosis
- B. Increased anteroposterior diameter of the chest
- C. Oxygen saturation level 96%
- D. Petechiae on chest
Correct answer: B
Rationale: COPD and emphysema are chronic respiratory conditions that can lead to changes in the shape of the chest. In clients with COPD, the anteroposterior diameter of the chest often increases, giving a barrel chest appearance. This change in chest shape is due to hyperinflation of the lungs and is a common physical finding in clients with COPD and emphysema. The other options are not typically associated with COPD and emphysema. Respiratory alkalosis is not a common finding in these clients. An oxygen saturation level of 96% is within the normal range and does not specifically relate to COPD. Petechiae on the chest are not typically associated with COPD or emphysema.
3. A client with chronic obstructive pulmonary disease is being taught by a nurse about ways to facilitate eating. Which of the following statements indicates a need for further teaching?
- A. I will rest for at least 30 minutes before eating.
- B. I will take my bronchodilators after meals.
- C. I will eat five or six small meals each day.
- D. I will choose foods that are not gas-forming.
Correct answer: B
Rationale: Option B, 'I will take my bronchodilators after meals,' indicates a need for further teaching. Bronchodilators should be taken before meals to help open the airways and make breathing easier before eating. This statement suggests a misunderstanding of the timing for optimal bronchodilator effectiveness. Options A, C, and D are all appropriate strategies for facilitating eating for a client with chronic obstructive pulmonary disease.
4. A client with newly diagnosed osteoporosis is being taught about lifestyle modifications. Which instruction should be included?
- A. Increase intake of caffeinated beverages.
- B. Engage in weight-bearing exercises regularly.
- C. Avoid exposure to sunlight.
- D. Take calcium supplements with iron.
Correct answer: B
Rationale: Engaging in weight-bearing exercises is crucial for individuals with osteoporosis as it helps strengthen bones and reduce the risk of fractures. Weight-bearing exercises include activities like walking, jogging, dancing, and strength training. These exercises help improve bone density and overall bone health, making them an essential component of lifestyle modifications for individuals with osteoporosis.
5. A client was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer?
- A. Ciprofloxacin
- B. Fluconazole
- C. Tobramycin
- D. Vancomycin
Correct answer: A
Rationale: In the case of anthrax exposure, the recommended antibiotic for prophylaxis and treatment is Ciprofloxacin. Ciprofloxacin is effective against the anthrax bacterium, Bacillus anthracis. Fluconazole is an antifungal medication, Tobramycin is an aminoglycoside antibiotic used for bacterial infections, and Vancomycin is a glycopeptide antibiotic primarily used for Gram-positive bacterial infections. Therefore, the correct choice is Ciprofloxacin.
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