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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: C
Rationale: Stripping the drainage tubing is an outdated practice and can cause complications.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. Which of the following vascular system changes result from aging?
- A. Increased peripheral resistance of the blood vessels
- B. Decreased blood flow
- C. Increased workload of the left ventricle
- D. All of the above
Correct answer: D
Rationale: As individuals age, various changes occur in the vascular system. These changes include increased peripheral resistance of the blood vessels, decreased blood flow, and an increased workload of the left ventricle. Therefore, all the listed changes result from aging, making option D, 'All of the above,' the correct answer.
3. A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
4. Which of the following is the correct abbreviation for drops?
- A. Gtt.
- B. Gtts.
- C. Dp.
- D. Dr.
Correct answer: A
Rationale: The correct abbreviation for drops in medical terminology is 'Gtt.' It is derived from the Latin word 'guttae,' meaning drops. The abbreviation 'Gtts.' (Choice B) is incorrect as it adds an unnecessary 's.' Choices C and D, 'Dp.' and 'Dr.,' are not standard abbreviations for drops in medical contexts, making them incorrect.
5. A healthcare professional is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the healthcare professional make in the medical record?
- A. Morphine 3 mg Subcutaneous every 4 hr. PRN for pain.
- B. Morphine 3 mg Subcutaneous
- C. Morphine 3.0 mg subcutaneously every 4 hr. PRN for pain.
- D. Morphine 3 mg Subcutaneous q 4 hr. PRN for pain.
Correct answer: D
Rationale: The correct entry for documenting the prescription for morphine is 'Morphine 3 mg Subcutaneous'. This entry accurately specifies the medication, dosage, route of administration, and frequency as prescribed by the provider. Options A, C, and D contain minor errors such as missing units of measurement or incorrect abbreviations, which could lead to misinterpretation or potential medication errors. Therefore, the most appropriate and accurate choice is 'Morphine 3 mg Subcutaneous'.
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