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. A healthcare provider is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the provider place at the client's bedside?
- A. Bag valve mask device
- B. Defibrillator machine
- C. Chest tube equipment
- D. Central venous catheter tray
Correct answer: A
Rationale: When a client receives a competitive neuromuscular blocking agent, it can lead to respiratory muscle paralysis. Placing a bag valve mask device at the client's bedside is crucial for providing immediate respiratory support in case of respiratory depression or failure. This device allows manual ventilation by squeezing the bag to deliver breaths to the client. The other options, such as a defibrillator machine, chest tube equipment, and central venous catheter tray, are not directly related to managing respiratory complications associated with neuromuscular blockade.
3. A nurse is caring for a client with a new diagnosis of type 1 diabetes. What is the most important aspect of teaching the nurse should focus on?
- A. The importance of regular exercise
- B. Proper administration of insulin
- C. Maintaining a low-carbohydrate diet
- D. Recognizing signs of hyperglycemia
Correct answer: B
Rationale: Proper administration of insulin is crucial for clients with type 1 diabetes as they are dependent on insulin for blood glucose control.
4. A healthcare professional is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
- A. Increased temperature
- B. Absent breath sounds
- C. Productive cough
- D. Incisional discomfort
Correct answer: B
Rationale: Absent breath sounds may indicate a pneumothorax, a serious complication post lung biopsy. This condition requires immediate attention to prevent respiratory distress.
5. When caring for a client with pneumonia, what intervention is most effective in preventing the spread of infection?
- A. Administer prescribed antibiotics on time.
- B. Encourage the client to use a tissue when coughing.
- C. Place the client in a private room.
- D. Perform hand hygiene before and after client contact.
Correct answer: D
Rationale: The most effective intervention to prevent the spread of infection when caring for a client with pneumonia is performing hand hygiene before and after client contact. This practice helps reduce the transmission of pathogens from one person to another, promoting infection control and maintaining a safe environment for both the client and healthcare provider.
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