ATI RN
ATI RN Exit Exam Quizlet
1. What is the priority nursing intervention for a patient experiencing respiratory distress?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer bronchodilators
- D. Administer IV fluids
Correct answer: A
Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, ensuring adequate oxygenation is the priority. Administering oxygen helps improve oxygen levels, which is crucial for the patient's well-being. Repositioning the patient, administering bronchodilators, or giving IV fluids are important interventions in certain situations, but when a patient is in respiratory distress, providing oxygen takes precedence over other actions.
2. A nurse is teaching a nutrition class for clients who have type 2 diabetes mellitus. Which of the following statements should the nurse include about management of acute illness?
- A. Consume carbs every 3-4 hrs
- B. Decrease fluid intake to 1000 mL per day
- C. Monitor blood glucose twice per day
- D. Check urine for ketones every 24 hrs
Correct answer: A
Rationale: The correct statement is to 'Consume carbs every 3-4 hours.' During acute illness, it is important to maintain a consistent carbohydrate intake to help manage blood glucose levels for clients with type 2 diabetes. This frequent consumption can prevent hypoglycemia and provide energy needed during illness. Decreasing fluid intake (choice B) is not recommended during acute illness, as hydration is crucial to prevent complications. Monitoring blood glucose (choice C) more frequently than twice a day is necessary during acute illness. Checking urine for ketones (choice D) should be done more frequently than once every 24 hours during illness to monitor for diabetic ketoacidosis.
3. In the ICU setting, a client transported from surgery following open heart bypass grafting will likely have his or her core temperature measured by:
- A. oral thermometer.
- B. rectal thermometer.
- C. esophageal thermometer.
- D. temporal artery thermometer.
Correct answer: C
Rationale: An esophageal thermometer is commonly used in ICU settings to accurately measure core body temperature, especially in post-surgical patients. The esophageal thermometer provides a more precise measurement of core temperature compared to other methods like oral, rectal, or temporal artery thermometers. In the ICU, accuracy in temperature measurement is crucial for detecting and responding to changes promptly, making the esophageal thermometer the preferred choice in this scenario.
4. What is the most appropriate action for a healthcare professional to take when a medication error occurs?
- A. Document the error in the patient's medical record.
- B. Report the error to the healthcare provider immediately.
- C. Apologize to the patient and explain what happened.
- D. Continue administering the medication and monitor the patient closely.
Correct answer: B
Rationale: When a medication error occurs, the most appropriate action for a healthcare professional is to report the error to the healthcare provider immediately. This is crucial for ensuring prompt corrective action to mitigate any potential harm to the patient. Documenting the error is important but should come after reporting it to the relevant authorities. Apologizing to the patient is important for maintaining trust and communication but should not take precedence over reporting and addressing the error. Continuing to administer the medication without addressing the error is unsafe and goes against patient safety protocols.
5. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?
- A. Assess the client's oxygen saturation.
- B. Notify the Rapid Response Team.
- C. Oxygenate the client with a bag-valve-mask.
- D. Palpate the skin of the upper chest.
Correct answer: A
Rationale: In this scenario, the client may have subcutaneous emphysema, where air leaks into the tissues surrounding the tracheostomy. The priority action for the nurse is to assess the client's oxygen saturation and other indicators of oxygenation to ensure adequate oxygen supply. If the client is stable, the nurse can then proceed to palpate the skin of the upper chest to check for subcutaneous emphysema. If the client is unstable, the nurse should promptly notify the Rapid Response Team. Using a bag-valve-mask device may be necessary for oxygenating the client, but assessing oxygen saturation comes first to guide further interventions.
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