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 client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Give morphine IV.
- B. Administer oxygen therapy.
- C. Start an IV infusion of lactated Ringer's.
- D. Initiate cardiac monitoring.
Correct answer: B
Rationale: Administering oxygen therapy is the priority intervention for a client with a pulmonary embolism. Oxygen helps improve oxygenation levels and decrease the workload on the heart. It is crucial to ensure adequate oxygenation before other interventions are initiated. Morphine IV, starting an IV infusion of lactated Ringer's, and initiating cardiac monitoring are important interventions but come after ensuring adequate oxygenation.
3. When working as a professional nurse, what is the priority for a new nurse working on an inpatient medical-surgical unit with a preceptor?
- A. Attending to holistic client needs
- B. Ensuring client safety
- C. Avoiding medication errors
- D. Providing client-focused care
Correct answer: B
Rationale: The priority for a nurse working on an inpatient medical-surgical unit is to ensure client safety. This is crucial as errors in hospital care can lead to preventable deaths. While attending to holistic client needs and providing client-focused care are important aspects of nursing, ensuring client safety takes precedence to prevent harm and promote positive patient outcomes.
4. A healthcare professional is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the healthcare professional expect?
- A. Bradycardia
- B. Bradypnea
- C. Lethargy
- D. Intercostal retractions
Correct answer: D
Rationale: Postoperative atelectasis can lead to hypoxia, which causes respiratory distress. Intercostal retractions, where the muscles between the ribs pull inward during inspiration, are a common sign of respiratory distress in a client with atelectasis. Bradycardia (slow heart rate), Bradypnea (slow breathing rate), and lethargy are not typically associated with atelectasis and hypoxia.
5. A client with asthma is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?
- A. Hypoglycemia
- B. Hypertension
- C. Polyuria
- D. Oral candidiasis
Correct answer: D
Rationale: Fluticasone is a corticosteroid often used to manage asthma. One of the common adverse effects associated with inhaled corticosteroids like fluticasone is oral candidiasis, also known as thrush. This fungal infection can develop in the mouth and throat due to the steroid's local immunosuppressive effects. Patients should be advised to rinse their mouths after using inhaled corticosteroids to reduce the risk of oral candidiasis. Monitoring for symptoms such as white patches, sore throat, or difficulty swallowing is essential to detect and manage this adverse effect promptly.
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