ATI RN
Adult Medical Surgical ATI
1. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?
- A. Raise the affected extremity above the level of the heart.
- B. Immobilize the affected extremity with a splint
- C. Apply ice to the bite area
- D. Apply a tourniquet to the affected extremity.
Correct answer: Immobilize the affected extremity with a splint
Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.
2. A healthcare provider is assessing a client who has a stage III pressure ulcer that is healing poorly. The provider should identify that which of the following vitamin deficiencies increases the client’s risk for delayed wound healing?
- A. Vitamin C
- B. Vitamin D
- C. Vitamin E
- D. Vitamin B6
Correct answer: A
Rationale: Corrected Rationale: Vitamin C deficiency can impair collagen synthesis and delay wound healing, making it crucial for recovery from pressure ulcers. Incorrect Rationales: - Vitamin D deficiency is associated with bone health, not specifically wound healing. - Vitamin E deficiency can lead to neurological and immune system issues but is not directly linked to delayed wound healing. - Vitamin B6 deficiency can cause skin rashes and neurological symptoms but is not a primary factor in delayed wound healing.
3. A nurse is reviewing blood glucose values for a client who is at risk for Diabetes Mellitus. Which of the following findings should the nurse report to the provider?
- A. 2 hr glucose tolerance test level 150 mg/dL
- B. Fasting blood glucose 70 mg
- C. Glycosylated hemoglobin 5%
- D. Casual blood glucose 90 mg/dL
Correct answer: A
Rationale: A 2-hour glucose tolerance test level of 150 mg/dL is above the normal range and should be reported to the provider as it indicates impaired glucose tolerance.
4. A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
- A. Hypotension
- B. Distended neck veins
- C. Slow capillary refill
- D. Weak, thready pulse
Correct answer: B
Rationale: The correct answer is B: 'Distended neck veins.' Distended neck veins are a sign of fluid volume excess, indicating an overload of fluids in the body. This can be caused by excessive fluid administration. Hypotension (choice A) is more commonly associated with fluid volume deficit. Slow capillary refill (choice C) and a weak, thready pulse (choice D) are also signs of decreased fluid volume, not fluid volume excess.
5. During a manic episode, which nursing intervention is most appropriate?
- A. Encourage group activities to increase socialization.
- B. Provide a structured environment with limited stimuli.
- C. Allow the patient to engage in physical activities freely.
- D. Give the patient detailed and complex tasks to complete.
Correct answer: B
Rationale: During a manic episode, individuals may experience heightened energy levels and reduced impulse control. Providing a structured environment with limited stimuli is the most appropriate nursing intervention. This approach helps reduce excessive stimulation and potential triggers for further escalation of manic behavior. It promotes a calming and controlled setting, assisting in managing symptoms and promoting the patient's well-being. Encouraging group activities (Choice A) may lead to overstimulation, allowing the patient to engage in physical activities freely (Choice C) could be risky due to impulsivity, and giving detailed tasks (Choice D) might overwhelm the individual.
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