ATI RN
ATI Fundamentals
1. A healthcare professional is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should NOT be included in the plan of care?
- A. Encourage the client to cough every 2 hours.
- B. Check for continuous bubbling in the suction chamber.
- C. Strip the drainage tubing every 4 hours.
- D. Obtain a chest x-ray
Correct answer: Strip the drainage tubing every 4 hours.
Rationale: Stripping the drainage tubing is an outdated practice and can cause complications. Encouraging the client to cough helps with lung expansion, checking for continuous bubbling ensures proper functioning of the chest tube system, and obtaining a chest x-ray helps to assess the position of the chest tube and re-expansion of the lung. Therefore, stripping the drainage tubing every 4 hours should not be included in the plan of care.
2. A nurse at a local health department is caring for a client who is newly diagnosed with listeriosis. Which of the following actions should the nurse plan to take?
- A. Provide the Centers for Disease Control (CDC) and Prevention with the client's information
- B. Inform the client that they are required to have health department staff directly observe their treatment
- C. Determine whether the condition is reportable under state requirements
- D. Find out whether the condition is endemic in the client's neighborhood
Correct answer: C
Rationale: The correct answer is C: 'Determine whether the condition is reportable under state requirements.' Listeriosis is a reportable disease, meaning healthcare providers are legally required to report cases to public health authorities. By checking the state requirements for reportable diseases, the nurse ensures compliance with public health regulations. Choice A is incorrect because providing the client's information to the CDC is not the immediate action needed. Choice B is incorrect as direct observation of treatment is not a standard procedure for listeriosis. Choice D is also incorrect as determining if the condition is endemic in the client's neighborhood is not the primary concern when managing a diagnosed case of listeriosis.
3. What are the most obvious organized patterns of behavior in a newborn baby?
- A. Reflexes
- B. States of arousal
- C. Shrill cries
- D. Sleep patterns
Correct answer: A
Rationale: The correct answer is A: Reflexes. Reflexes are automatic, involuntary responses to specific stimuli and are the most obvious organized patterns of behavior in a newborn baby. Examples of newborn reflexes include sucking, rooting, grasping, and the Moro reflex. These reflexes are crucial for the newborn's survival and overall development. Choice B, states of arousal, refers to different levels of consciousness and responsiveness, not organized behavior patterns. Choice C, shrill cries, is a form of communication and not an organized behavior pattern. Choice D, sleep patterns, while important for newborns, are not the most obvious organized behavior patterns.
4. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?
- A. The client with an abdominal aortic aneurysm who is constipated
- B. The client on bed rest who ambulated to the bathroom
- C. The client with essential hypertension who has epistaxis and a headache
- D. The client with arterial occlusive disease who has a decreased pedal pulse
Correct answer: C
Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis, requiring immediate intervention. Option A is incorrect as constipation in a client with an abdominal aortic aneurysm, though important, does not indicate an immediate need for assessment. Option B, a client on bed rest who ambulated to the bathroom, does not present with urgent signs or symptoms requiring immediate assessment. Option D, a client with arterial occlusive disease and a decreased pedal pulse, needs attention but is not the priority compared to a hypertensive crisis with epistaxis and headache.
5. A client is receiving furosemide for heart failure. Which of the following findings should the nurse report to the provider?
- A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
- B. Heart rate of 68/min.
- C. Potassium level of 3.8 mEq/L.
- D. Urine output of 60 mL/hr.
Correct answer: B
Rationale: The correct answer is B. A heart rate of 68/min is lower than expected and should be reported as it may indicate digoxin toxicity. Choices A, C, and D are within normal limits for a client receiving furosemide for heart failure and do not require immediate reporting. Weight loss may be expected due to diuretic therapy, a potassium level of 3.8 mEq/L is within the normal range, and a urine output of 60 mL/hr indicates adequate renal perfusion.
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