ATI RN
ATI Fundamentals
1. A client has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
- A. Teach the client to scan the right to see objects on the right side of their body.
- B. Place the bedside table on the right side of the bed.
- C. Orient the client to the food on their plate using the clock method.
- D. Place the wheelchair on the client's left side.
Correct answer: Place the bedside table on the right side of the bed.
Rationale: In a client with left homonymous hemianopsia, there is a loss of vision on the right side of both eyes. Placing the bedside table on the right side of the bed ensures that essential items are within the client's field of vision, minimizing the risk of injury or accidents. Teaching the client to scan to the right and orienting them using the clock method may be helpful strategies, but placing the bedside table on the right side of the bed is a more direct and immediate intervention to enhance the client's safety and independence.
2. A healthcare professional is educating a client who is starting therapy with topotecan. Which of the following findings should the professional instruct the client to report?
- A. Hair loss
- B. Fatigue
- C. Sore throat
- D. Red urine
Correct answer: C
Rationale: The correct answer is C: 'Sore throat.' Clients starting therapy with topotecan should be instructed to report a sore throat because it can indicate an infection due to the immunosuppressive effects of the medication. Infections can be serious in clients undergoing chemotherapy, so early detection and treatment are crucial to prevent complications. Choices A, B, and D are incorrect because while they are potential side effects of topotecan, they are usually not as immediately concerning as a sore throat, which could signal a serious infection requiring prompt attention.
3. While assessing a patient's peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
- A. Air emboli
- B. Phlebitis
- C. Infiltration
- D. Fluid overload
Correct answer: C
Rationale: Infiltration is the administration of a nonvesicant solution or medication into the surrounding tissue, typically due to the dislodgement or perforation of the vein wall by the IV cannula. It is characterized by edema around the insertion site, leakage of IV fluid, discomfort, coolness, and a decrease in flow rate. In this scenario, the presence of edema indicates infiltration, not air emboli, phlebitis, or fluid overload. Air emboli refer to air bubbles in the bloodstream, phlebitis is inflammation of the vein, and fluid overload is an excessive volume of fluid in the circulatory system.
4. A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?
- A. Hematocrit of 46%
- B. Hemoglobin of 13.8 g/dL
- C. Elevated reticulocyte count
- D. Decreased white blood cell (WBC) count
Correct answer: C
Rationale: The correct answer is C: Elevated reticulocyte count. Hemorrhage leads to the release of reticulocytes (immature red blood cells) from the bone marrow into circulation as a compensatory mechanism to replenish lost red blood cells. This response helps in restoring the oxygen-carrying capacity of the blood. Choices A and B, hematocrit of 46% and hemoglobin of 13.8 g/dL, may not reflect the immediate response to hemorrhage within 14 hours. Choice D, decreased white blood cell (WBC) count, is not directly related to the body's response to hemorrhage.
5. Which of the following scenarios represents nursing malpractice?
- A. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and suffers cerebral damage due to anoxia.
- B. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.
- C. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus.
- D. The nurse administers the wrong medication to a patient, resulting in vomiting. This error is documented and reported to the physician and the nursing supervisor.
Correct answer: A
Rationale: The correct answer is A. Administering a drug to a patient with a known allergy, leading to severe harm such as an allergic reaction causing cerebral damage due to anoxia, constitutes nursing malpractice. In this scenario, the nurse failed to adhere to the standard of care by administering a medication that the patient was allergic to, resulting in serious harm, which is a clear example of malpractice in nursing.
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