ATI RN
ATI RN Pharmacology 2019 III Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
Correct Answer: B
Rationale: The correct answer is B: Continue to monitor the client. When there is a rise in the water seal chamber with client inspiration, it indicates that there is increased pressure in the pleural space. By continuing to monitor the client, the nurse can assess for any signs of respiratory distress or worsening conditions. Repositioning the client toward the left side (choice
A) may not address the underlying issue and could potentially worsen the situation. Clamping the chest tube near the water seal (choice
C) is not recommended as it can lead to a tension pneumothorax. Immediately notifying the provider (choice
D) may not be necessary at this point since further assessment is needed.
Therefore, the best course of action is to continue monitoring the client closely to observe for any changes in condition.
Question 2 of 5
A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed head injury. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Place the client in a supine position. Placing the client in a supine position helps promote venous drainage from the brain, which can help reduce intracranial pressure. This position also helps maintain cerebral perfusion pressure.
Choice A is incorrect because log rolling can increase ICP due to the movement involved.
Choice B is incorrect as coughing and deep breathing can also raise ICP.
Choice C is incorrect because a warming blanket can lead to vasodilation and increased blood flow to the brain, potentially worsening ICP.
Question 3 of 5
A nurse is teaching a 12yearold child who is newly diagnosed with asthma about managing the condition to prevent asthma attacks. Which of the following statements by the child should indicate to the nurse that the teaching has been effective?
Correct Answer: A
Rationale:
Correct
Answer: A
Rationale:
1. Eliminating allergens that irritate my lungs can help me avoid getting an asthma attack.
- This statement shows understanding of asthma triggers and prevention, indicating effective teaching.
2. If I control my asthma, I will miss fewer days of school.
- This statement focuses on the outcome rather than the preventive measures.
3. Even if I control my asthma well, I won't be able to participate in sports or physical activities.
- This statement is negative and does not reflect the positive impact of managing asthma.
4. Coughing and shortness of breath in the morning can be a sign that my asthma is well controlled.
- This statement is incorrect as symptoms like coughing and shortness of breath indicate poor asthma control.
Question 4 of 5
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Correct Answer: A
Rationale: The correct answer is A: Oral mucosa. Central cyanosis is characterized by bluish discoloration of the mucous membranes and is indicative of decreased oxygen saturation in the arterial blood. The oral mucosa is a highly vascular area where cyanosis can be easily observed. The nurse should assess the lips, gums, and tongue for bluish discoloration. Conjunctivae, ear lobes, and soles of the feet are not reliable indicators of central cyanosis as they are less vascular areas and may not show cyanosis as clearly as the oral mucosa. In summary, the oral mucosa is the most reliable indicator of central cyanosis due to its rich vascularity and ease of observation.
Question 5 of 5
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?
Correct Answer: B
Rationale: The correct answer is B: Checking the pupillary response to light. Cranial nerve III, also known as the oculomotor nerve, controls the pupillary constriction in response to light.
To assess this nerve, the nurse should shine a light into the client's eyes and observe for constriction of the pupils. This action tests the functionality of cranial nerve III specifically.
Other choices are incorrect:
A: Eliciting the gag reflex assesses cranial nerve IX, the glossopharyngeal nerve.
C: Observing for facial symmetry assesses cranial nerve VII, the facial nerve.
D: Testing visual acuity assesses cranial nerve II, the optic nerve.
Therefore, choice B is correct for assessing cranial nerve III, while the other choices are for assessing different cranial nerves.