ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
A client is recently diagnosed with pneumonia. The nurse observes the client sitting upright in the bed and assesses a respiratory rate of 26. The client states I can't catch my breath. Which abbreviation would be used to document this presentation?
Correct Answer: C
Rationale: The correct answer is C: SOB. SOB stands for shortness of breath, which accurately describes the client's symptom of difficulty catching their breath, indicating respiratory distress. The client sitting upright and having an increased respiratory rate of 26 further supports the presence of respiratory distress.
A: R/O (rule out) is used to indicate a possible diagnosis that has not been confirmed yet, not appropriate in this context.
B: S/P (status post) is used to indicate a past medical event or surgery, not relevant to the client's current presentation.
D: DOB (date of birth) is not related to the client's respiratory symptoms and is not appropriate for this scenario.
Question 2 of 5
The nurse is giving vancomycin to a client and must hold the dose until the results of the trough level are known. This term is associated with the point at which the:
Correct Answer: C
Rationale: The correct answer is C: Blood serum drug concentration is lowest. A trough level is the lowest concentration of a drug in the bloodstream before the next dose is given. Holding the dose until the trough level is known ensures the drug is not given too soon, preventing toxicity and maintaining therapeutic levels.
Choice A is incorrect as it describes the concept of half-life, not trough level.
Choice B is incorrect as toxicity is not specifically related to trough levels.
Choice D is incorrect as it refers to peak concentration, not trough level.
Question 3 of 5
A client is diagnosed with chronic constipation. The nurse is given an order by the physician to administer a glycerin suppository. What abbreviation will be written in the physician's order for the administration route for the suppository?
Correct Answer: D
Rationale: The correct answer is D: PR. "PR" stands for "per rectum," which means the suppository will be administered through the rectum. This route is appropriate for glycerin suppositories as they are designed to stimulate bowel movement by irritating the rectal mucosa. The other choices are incorrect: A: S/P means status post, B: RS is not a standard abbreviation for a suppository route, and C: R is not a recognized abbreviation for the rectal route.
Therefore, PR is the correct abbreviation for the physician's order.
Question 4 of 5
The nurse is caring for a client who is at high risk for development of pressure injury. The client is able to move independently but has been placed on bedrest. The client has experienced two episodes of urinary incontinence. Which intervention(s) should the nurse include in the care plan?
Correct Answer: A,D,E
Rationale: The correct interventions are A, D, and E. A is correct because frequent weight shifting promotes circulation and reduces pressure on skin. D is important to protect the skin from moisture-related damage. E is necessary to prevent pressure injuries by using appropriate support surfaces. B is incorrect as it does not directly address pressure injury prevention. C is incorrect as massaging bony prominences can increase the risk of pressure injuries.
Question 5 of 5
A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to:
Correct Answer: C,E
Rationale: The correct answers are C and E. A serum potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to serious complications like cardiac arrhythmias.
Choice C is correct because assessing the client for muscle weakness and flaccid paralysis helps to monitor for potential cardiac issues.
Choice E is also correct as obtaining a physician's order for cardiac monitoring is crucial to continuously monitor the client's cardiac status.
Choices A, B, and D are incorrect.
Choice A is not a priority as diluting potassium elixir does not address the immediate risk of hyperkalemia.
Choice B is not the highest priority as it does not address the urgent need to monitor for cardiac complications.
Choice D is incorrect as encouraging intake of potassium-rich foods can worsen hyperkalemia.