ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Exibit 1
Medication Administration Record 0800:
Amoxicillin 500 mg PC every 8 hr
Exibit 2
Nurses' Notes
0800:
Antibiotic administered as prescribed.
Bilateral breath sounds clear and present throughout
0830
Client reports itching over the chest area and has urticaria over chest and trunk
Client states tongue feels swollen.
Bilateral breath sounds with scattered wheezing upon auscultation.
Exibit 3
Vital Signs
0800:
Temperature 37.6° C (99.7° F)
Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min
Pulse oximetry 97% on room air
0830
Temperature 37.5° C (99.5° F)
Blood pressure 88/56 mm Hg
Heart rate 104/min
Respiratory rate 24/min
Pulse oximetry 93% on room air
Question 1 of 5
A nurse is caring for a client. Select the 4 findings that require immediate follow-up.
Correct Answer: B,C,D,E
Rationale: The correct findings that require immediate follow-up are breath sounds, blood pressure, heart rate, and swollen tongue. Breath sounds are essential to assess respiratory status. Blood pressure and heart rate indicate cardiovascular function. A swollen tongue could indicate an allergic reaction or airway compromise. Temperature, urticaria, and an absent option do not necessarily require immediate follow-up as they may not directly impact the client's immediate health status.
Extract:
Question 2 of 5
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Secure the tracheostomy in place with a collar that has hook-and-loop fasteners. This is essential to prevent accidental dislodgement of the tracheostomy tube. Using a collar with hook-and-loop fasteners ensures a secure and adjustable fit.
Choice A is incorrect because placing gauze under the flanges can create pressure points and increase the risk of tissue damage.
Choice C is incorrect as clean gloves may not provide adequate protection; sterile gloves should be used to prevent infection.
Choice D is incorrect as full-strength hydrogen peroxide can be harsh on the skin and may cause irritation.
Question 3 of 5
A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?
Correct Answer: C
Rationale: The correct answer is C: Place an activated tuning fork in the middle of the client's forehead. This is the appropriate action for the Weber's test because it helps assess for asymmetrical hearing loss. Placing the tuning fork on the forehead allows sound to be conducted through bone, bypassing the outer and middle ear. If the client hears the sound more in one ear than the other, it indicates conductive hearing loss in the ear that hears it less. Whispering words (
B) and delivering high-pitched sounds (
A) are not part of the Weber's test. Holding the tuning fork against the mastoid process (
D) is part of the Rinne test, not the Weber's test.
Question 4 of 5
A nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?
Correct Answer: B
Rationale: The correct answer is B: Walk for 30 minutes three to five times each week. Weight-bearing exercises, like walking, help improve bone density and prevent osteoporosis. Walking also helps strengthen muscles and improve balance, reducing the risk of falls and fractures. Performing water aerobics (choice
A) can be beneficial for overall health but may not have the same impact on bone density as weight-bearing exercises. Increasing intake of vitamin B12 (choice
C) is important for overall health but not specifically for osteoporosis prevention. Maintaining a lean body mass (choice
D) is beneficial, but the focus should be on weight-bearing exercises for osteoporosis prevention.
Question 5 of 5
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale: The correct actions for the nurse to take in this scenario are A, B, D, and E. A diuretic can help manage fluid overload, oxygen can help alleviate hypoxia, stopping the transfusion is crucial to prevent further complications, and placing the client in high-Fowler's position can improve oxygenation. Administering epinephrine is not indicated as it is not a standard treatment for these symptoms. Obtaining a prescription for a diuretic is more urgent than administering one as the client is already showing signs of fluid overload. Administering epinephrine without assessing the client's condition further could worsen their symptoms.