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: A
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. When caring for a client with Alzheimer's disease, what is the most appropriate communication technique for a nurse to use?
- A. Providing detailed explanations
- B. Speaking in a loud and clear voice
- C. Using simple and direct statements
- D. Offering multiple choices to the client
Correct answer: C
Rationale: When communicating with clients with Alzheimer's disease, using simple and direct statements is the most appropriate technique. This approach helps to minimize confusion, enhance understanding, and facilitate effective communication with individuals who may have difficulty processing complex information due to their condition.
3. A nurse teaches a client with tuberculosis (TB) who is being discharged. Which statement by the client indicates a need for further teaching?
- A. I will take my medication as prescribed.
- B. I will need to have regular follow-up chest x-rays.
- C. I will be able to return to work immediately.
- D. I will use tissues to cover my mouth when I cough.
Correct answer: C
Rationale: Clients with tuberculosis should not return to work until they are no longer contagious and have been cleared by their healthcare provider. This usually requires several weeks of treatment. The other statements are correct and indicate understanding.
4. A client is prescribed albuterol (Proventil) via a metered-dose inhaler. Which action should the nurse take to ensure effective use of this medication?
- A. Instruct the client to inhale quickly while administering the medication.
- B. Have the client hold their breath for 10 seconds after inhaling the medication.
- C. Tell the client to exhale immediately after inhaling the medication.
- D. Encourage the client to use the inhaler as needed only when experiencing symptoms.
Correct answer: B
Rationale: To ensure effective use of albuterol via a metered-dose inhaler, the nurse should have the client hold their breath for 10 seconds after inhaling the medication. This action allows the medication to reach deeper into the airways. Inhaling slowly and deeply, not quickly, is recommended for optimal drug delivery. Exhaling immediately after inhaling the medication would expel it before it can take effect. It's essential for the client to follow the prescribed regimen of medication usage, not just using the inhaler when symptoms are present.
5. A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?
- A. Constant bubbling in the suction-control chamber
- B. Continuous bubbling in the water-seal chamber
- C. Bloody drainage in the collection chamber
- D. Fluid-level fluctuations in the water-seal chamber
Correct answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak, which can compromise the system's integrity and affect the client's respiratory status. The other options are expected findings in a client with a chest tube drainage system: constant bubbling in the suction-control chamber indicates proper suction function, bloody drainage in the collection chamber is expected in the immediate postoperative period, and fluid-level fluctuations in the water-seal chamber demonstrate normal drainage and lung re-expansion.
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