ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?
Correct Answer: A
Rationale: The correct answer is A: A sharp decrease in blood pressure. An anaphylactic reaction is a severe allergic reaction that can occur rapidly after exposure to an allergen, such as medication. It can lead to a sudden drop in blood pressure due to widespread vasodilation and increased permeability of blood vessels. This can result in shock, a life-threatening condition.
Therefore, the nurse should identify a sharp decrease in blood pressure as a key indicator of an anaphylactic reaction.
Choices B, C, and D are incorrect as they are not typical signs of an anaphylactic reaction. Swelling in the feet, pain at the injection site, and a sudden decrease in heart rate are not specific to anaphylaxis.
Question 2 of 5
A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion?
Correct Answer: D
Rationale: The correct answer is D: Check the blood product's compatibility with the client's blood type. This step is crucial to prevent a transfusion reaction, as administering incompatible blood can be life-threatening. The nurse should verify the blood product against the client's blood type and Rh factor to ensure compatibility.
A: Priming the IV tubing with lactated Ringer's is not necessary before administering packed RBCs and does not ensure the blood product's compatibility.
B: Confirming the client's identity with the blood bank technician is important but does not directly relate to ensuring the blood product's compatibility.
C: Checking for a small gauge IV catheter is important for infusion, but it is not directly related to ensuring the blood product's compatibility.
Overall, the priority before administering packed RBCs is to confirm compatibility with the client's blood type to prevent adverse reactions.
Question 3 of 5
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
Correct Answer: C
Rationale:
Correct Answer: C. Prepare the client for a central venous line.
Rationale: PN with high osmolarity and high glucose concentration can cause vein irritation and damage peripheral veins.
Therefore, the use of a central venous line is appropriate to minimize the risk of complications like phlebitis and thrombophlebitis.
Incorrect
Choices:
A: Obtaining a random blood glucose daily is important for monitoring blood glucose levels in clients receiving PN, but it does not address the need for a central venous line.
B: Changing the PN infusion bag every 48 hours is a standard practice to prevent contamination but does not address the need for a central venous line.
D: Administering the PN and fat emulsion separately is not necessary as they are often combined in one infusion for convenience and efficiency.
Question 4 of 5
A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Inject 5.1 cm (2 in) away from the umbilicus. This instruction is important to prevent any damage to the abdominal organs near the umbilicus. Injecting heparin too close to the umbilicus can lead to injury or bleeding.
Choice A is incorrect because an 18-gauge, 1-inch needle is too large for subcutaneous injections like heparin administration.
Choice B is incorrect as massaging the injection site after withdrawing the needle can increase the risk of bruising or bleeding.
Choice D is incorrect as expelling air bubbles before injecting medication is essential for intravenous injections, not subcutaneous injections like heparin.
Question 5 of 5
A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?
Correct Answer: B
Rationale: The correct answer is B: Right lateral in Trendelenburg position. Placing the client in a right lateral position helps target the left lower-lobe atelectasis by allowing drainage of secretions from that specific area. Trendelenburg position further aids in promoting drainage due to the head being lower than the feet, assisting gravity in moving secretions. Other options are incorrect as they do not provide the specific positioning needed to target the left lower-lobe atelectasis effectively. Side-lying with the right side of the chest elevated would not facilitate drainage from the affected lobe. Placing the client prone with pillows under the lower extremities or supine in low-Fowler's position would not target the specific area requiring drainage.