a nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal t

ATI RN

ATI Fundamentals

1. A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

A. Apply a vest restraint if self-extubation is attempted.
B. Monitor ventilator settings every 8 hours.
C. Document tube placement in centimeters at the angle of the jaw.
D. Assess breath sounds every 1 to 2 hours.

Correct answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

2. Which hormone is secreted by the Islets of Langerhans?

A. Progesterone
B. Testosterone
C. Insulin
D. Hemoglobin

Correct answer: C

Rationale: Insulin is the correct answer. It is the hormone secreted by the Islets of Langerhans in the pancreas. These specialized cells regulate blood sugar levels by releasing insulin in response to high blood glucose levels. Insulin aids in glucose absorption by cells, lowering blood sugar levels. Progesterone, testosterone, and hemoglobin are not secreted by the Islets of Langerhans and do not play a role in blood sugar regulation.

3. When is additional Vitamin C not required?

A. Infancy
B. Young adulthood
C. Childhood
D. Pregnancy

Correct answer: B

Rationale: Vitamin C requirements are increased during infancy, childhood, and pregnancy due to growth and development. However, during young adulthood, the body generally requires a consistent amount of Vitamin C as it is not undergoing rapid growth or physiological changes that necessitate an increase in Vitamin C intake.

4. What is the primary purpose of handwashing?

A. To promote hand circulation
B. To prevent the transfer of microorganisms
C. To avoid touching the client with a dirty hand
D. To provide comfort

Correct answer: B

Rationale: The primary purpose of handwashing is to prevent the transfer of microorganisms. Proper hand hygiene helps reduce the risk of spreading harmful bacteria and viruses, thus promoting overall health and preventing infections. Choice A is incorrect as handwashing primarily focuses on cleanliness rather than promoting circulation. Choice C is incorrect as it implies that the main concern is avoiding client discomfort rather than preventing infection. Choice D is incorrect as while handwashing can be comforting in some situations, its primary purpose is not to provide comfort but to maintain hygiene.

5. A patient requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?

A. Diabetes mellitus
B. Shoulder presentation
C. Postterm with oligohydramnios
D. Chorioamnionitis

Correct answer: C

Rationale: Postterm pregnancy with oligohydramnios is a contraindication for the use of oxytocin due to the increased risk of uterine hyperstimulation and fetal distress. Oxytocin can further stress the fetus in this scenario, potentially leading to adverse outcomes. Therefore, it is crucial for the nurse to recognize this contraindication to ensure the safety of both the mother and the baby during labor.