ATI RN
ATI Perfusion Questions
1. The nurse is caring for a patient in the cardiac unit recovering from a cardiac bypass graft procedure. The patient's spouse comes out to the hallway and expresses concern about the patient's confusion since surgery was 3 days ago. An appropriate response by the nurse would be:
- A. Let me call the doctor right away.
- B. What specific concerns do you have?
- C. It is common for confusion to occur after this procedure.
- D. I'll have the counselor come meet you in the room.
Correct answer: It is common for confusion to occur after this procedure.
Rationale: Choice C is the correct answer because confusion can be a common occurrence after cardiac surgeries due to factors such as anesthesia, medication, and the stress of the procedure. By acknowledging the spouse's concern and explaining that confusion is a known potential outcome, the nurse provides reassurance and education. Choices A, B, and D are incorrect because they do not directly address the spouse's concern about the patient's confusion or provide appropriate information about the situation.
2. A 10-year-old male is stung by a bee while playing in the yard. He begins itching and develops pain, swelling, redness, and respiratory difficulties. He is suffering from:
- A. Immunodeficiency
- B. Autoimmunity
- C. Anaphylaxis
- D. Tissue-specific hypersensitivity
Correct answer: C
Rationale: The correct answer is C: Anaphylaxis. Anaphylaxis is a severe, immediate allergic reaction mediated by IgE. In this scenario, the symptoms of itching, pain, swelling, redness, and respiratory difficulties following a bee sting are indicative of anaphylaxis. Choice A, Immunodeficiency, refers to a weakened immune system's inability to protect the body from infections and diseases, which is not the case here. Choice B, Autoimmunity, involves the immune system attacking healthy cells and tissues by mistake, which is not the mechanism at play in anaphylaxis. Choice D, Tissue-specific hypersensitivity, does not accurately describe the immediate, systemic reaction seen in anaphylaxis.
3. Which nursing action(s) can result in disciplinary action by state boards of nursing?
- A. Release of client health information to a client’s neighbor
- B. Delegation of a dressing change to unlicensed assistive personnel (UAP)
- C. Release of client health information to the client’s durable power of attorney
- D. A, B
Correct answer: D
Rationale: The correct answer is D. Disclosing client health information to unauthorized individuals like a client's neighbor (A) and improper delegation of tasks to unlicensed personnel (B) are serious violations of patient confidentiality and safety standards, which can lead to disciplinary action by state boards of nursing. Choice C, releasing client health information to the client's durable power of attorney, is not a violation as it involves sharing information with an authorized individual. Therefore, choices A and B are incorrect, making D the correct answer.
4. A client with Crohn’s disease is receiving parenteral nutrition. Which of the following interventions should the nurse not include in the care of this client?
- A. Remove the parenteral nutrition solution from the refrigerator 2 hours before infusion.
- B. Remove unused parenteral nutrition after 12 hours of use.
- C. Monitor daily laboratory values and report abnormalities as needed.
- D. Monitor the flow rate of the parenteral nutrition carefully and adjust it if necessary.
Correct answer: Remove unused parenteral nutrition after 12 hours of use.
Rationale: In caring for a client receiving parenteral nutrition, it is important to follow proper guidelines to ensure safety and effectiveness. Unused parenteral nutrition should be removed after 24 hours, not 12 hours, to prevent contamination and reduce the risk of infection. Option A is correct as it ensures the solution is at room temperature before infusion. Option C is essential for monitoring the client's response to parenteral nutrition. Option D is important to maintain the correct flow rate and adjust it as needed. Therefore, option B is the incorrect choice among the options provided.
5. A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, 'I don't understand why my child is so upset. I've never seen my child act this way around others before.' Which of the following statements should the nurse make?
- A. This is a normal, expected reaction for a child of this age.
- B. This is a response to an overstimulating environment.
- C. This is a common reaction to an overexposure to caregivers.
- D. This is a typical reaction for a child who is sick.
Correct answer: This is a normal, expected reaction for a child of this age.
Rationale: The correct answer is 'This is a normal, expected reaction for a child of this age.' Separation anxiety typically peaks around 8-10 months of age, leading to distress when separated from caregivers. Choice B is incorrect because the infant's behavior is more likely due to separation anxiety rather than overstimulation. Choice C is incorrect as the infant's behavior is not related to overexposure to caregivers but rather a natural developmental stage. Choice D is incorrect as the infant's behavior is not indicative of illness but rather a normal emotional response.
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