ATI RN
Adult Medical Surgical ATI
1. A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?
- A. Provide respiratory support.
- B. Place the client in droplet isolation.
- C. Administer antihypertensive medications.
- D. Monitor ascites.
Correct answer: Provide respiratory support.
Rationale: In the late stage of inhalation anthrax, respiratory support is crucial due to the potential for respiratory failure. Providing oxygen therapy and maintaining airway patency are essential components of care to improve oxygenation and support respiratory function. Placing the client in droplet isolation is not necessary as inhalation anthrax is not transmitted from person to person through respiratory droplets. Administering antihypertensive medications is not indicated in the treatment of inhalation anthrax. Monitoring for ascites is not a priority in the late stage of inhalation anthrax.
2. The healthcare professional must verify the client’s identity before the administration of medication. Which of the following is the safest way to identify the client?
- A. Ask the client for their name
- B. Check the client’s identification band
- C. State the client’s name aloud and ask the client to repeat it
- D. Check the room number
Correct answer: B
Rationale: Verifying the client's identity before administering medication is crucial to ensure patient safety. Checking the client’s identification band is the safest and most reliable method to confirm the client's identity. Identification bands are specifically designed to prevent errors in patient identification and help healthcare professionals administer care to the correct individual. Asking the client for their name (Choice A) may lead to errors if the client is unable to communicate or if there is a language barrier. Stating the client’s name aloud and asking them to repeat it (Choice C) relies on the client's ability to respond accurately. Checking the room number (Choice D) does not directly confirm the client's identity and may lead to errors if multiple patients are in the same room.
3. A client at 10 weeks of gestation reports frequent nausea and vomiting. Which of the following instructions should the nurse include?
- A. Eat high-protein foods.
- B. Lie down after meals.
- C. Drink water with meals.
- D. Eat dry carbohydrates before getting out of bed.
Correct answer: D
Rationale: During early pregnancy, nausea and vomiting are common. Instructing the client to eat dry carbohydrates like crackers before getting out of bed can help alleviate these symptoms. This recommendation helps prevent an empty stomach, which can worsen nausea. High-protein foods (Choice A) may be harder to digest and could exacerbate nausea. Lying down after meals (Choice B) may increase gastric reflux and worsen symptoms. Drinking water with meals (Choice C) may make the client feel fuller, potentially worsening nausea.
4. A 4-month-old infant is discharged home after surgery for the repair of a cleft lip. What should instructions to the parents include?
- A. Provide crib toys for distraction
- B. Breast- or bottle-feeding can begin immediately
- C. Give pain medication to the infant to minimize crying
- D. Leave the infant in the crib at all times to prevent suture strain
Correct answer: C
Rationale: Pain management is essential postoperatively to reduce crying, which could place strain on the surgical site. Feeding and holding the infant are allowed, but care should be taken to avoid placing pressure on the suture line.
5. A nurse is planning to administer a blood transfusion to a client. Which of the following should the nurse do to prevent an adverse transfusion reaction?
- A. Verify the client's blood type with the provider's prescription
- B. Ensure the client's consent for the transfusion is on file
- C. Administer a diuretic prior to starting the transfusion
- D. Check the client's temperature prior to the transfusion
Correct answer: A
Rationale: The correct answer is to verify the client's blood type with the provider's prescription. This is crucial to prevent an adverse transfusion reaction due to incompatibility. Ensuring the blood type matches before starting the transfusion is a standard safety practice. Option B, ensuring client consent, is important but not directly related to preventing a transfusion reaction. Option C, administering a diuretic, is unnecessary and can be harmful in this context. Option D, checking the client's temperature, is important for general assessment but not specifically focused on preventing a transfusion reaction.
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