ATI RN
ATI Nur 104 Fundamentals Final Exam Questions
Question 1 of 5
A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?
Correct Answer: D
Rationale: The correct answer is D: Check the patency of the client's airway. During a seizure, the client may experience airway obstruction due to the positioning of the tongue or secretions. Maintaining a clear airway is the priority to ensure adequate oxygenation. Positioning the client side-lying (choice
B) is important to prevent aspiration but comes after ensuring a patent airway. Identifying the amount of poison ingested (choice
A) and determining the specific poison (choice
C) are important for treatment but not immediate priorities during a seizure.
Question 2 of 5
A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?
Correct Answer: D
Rationale: Subjective data is information provided by the client based on their feelings, perceptions, or symptoms. Nausea is a subjective symptom that the client reports, making it the correct choice. Petechiae, cyanosis, and blood pressure are objective data that can be measured or observed. Petechiae and cyanosis are physical signs, while blood pressure is a measurable clinical parameter.
Therefore, choices A, B, and C are incorrect as they are objective data.
Question 3 of 5
A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?
Correct Answer: B
Rationale: The correct answer is B: Urticaria. Diphenhydramine is an antihistamine that can help manage allergic reactions like urticaria (hives) by blocking histamine release. Hemolysis (choice
A) is a reaction where RBCs are destroyed, not an allergic response. Fever (choice
C) can be a sign of a febrile non-hemolytic transfusion reaction, not directly related to histamine release. Fluid overload (choice
D) is a transfusion reaction due to excessive volume, not an allergic response. Administering diphenhydramine is focused on managing histamine-related symptoms like urticaria in this scenario.
Question 4 of 5
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?
Correct Answer: A
Rationale: The correct answer is A: Reporting laboratory findings to a member of the client's family. This violates client confidentiality as it discloses sensitive health information without the client's consent. Family members are not automatically authorized to receive such information. Discussing a client's surgical procedure with the nurse manager (
B) is appropriate within the healthcare team. Notifying the provider of physical examination findings (
C) is part of the standard communication process in healthcare. Identifying the client by name when making a referral for home health services (
D) is necessary for continuity of care and is not a breach of confidentiality.
Question 5 of 5
A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?
Correct Answer: C
Rationale:
Correct
Answer: C - The client holds his breath for 10 seconds after inhaling the medication.
Rationale: Holding the breath for 10 seconds after inhaling the medication allows the medication to be fully absorbed into the lungs, maximizing its effectiveness in treating asthma symptoms. This action ensures that the medication reaches deeper into the airways where it is needed most. By holding the breath, the client also prevents the medication from being exhaled too quickly, giving it more time to work.
Summary of other choices:
A: The client waiting 10 minutes between inhalations is not recommended as it may delay the client from receiving the full benefits of the medication promptly.
B: Taking a quick inhalation while releasing the medication from the inhaler may not allow the client to fully inhale the medication into the lungs, reducing its effectiveness.
D: Exhaling as the medication is released from the inhaler may result in the medication being exhaled before it can be properly absorbed, reducing its therapeutic effects.