ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Question 1 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: C
Rationale: The correct answer is C: Side-lying with the right side of the chest elevated. This position allows gravity to help drain secretions from the left lower lobe, promoting lung expansion. Placing the client in a side-lying position with the right side elevated facilitates drainage and prevents pooling of secretions. Option A (Prone with pillows under the lower extremities) would not effectively target the left lower lobe. Option B (Supine in low-Fowler's position) may not provide adequate drainage for the specific lobe affected. Option D (Right lateral in Trendelenburg position) is incorrect as Trendelenburg position is not recommended for postural drainage due to increased risk of complications.
Question 2 of 5
A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make?
Correct Answer: D
Rationale: The correct answer is D: "We can discuss what you can expect during your stay." This statement acknowledges the client's feelings of anxiety and offers support by providing information to help alleviate their fears. It promotes open communication, builds trust, and empowers the client by involving them in the care process. It also addresses the client's need for information and helps them feel more prepared for their stay.
Choice A is incorrect as it focuses on the client's fear rather than providing reassurance or support.
Choice B is incorrect as it generalizes the client's feelings without addressing their specific concerns.
Choice C is incorrect as it dismisses the client's anxiety without offering any information or support.
Question 3 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 4 of 5
A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?
Correct Answer: C
Rationale: The correct answer is C: Review the use of an artificial larynx with the client. This is the priority intervention because after a total laryngectomy, the client will need alternative methods for speech, and an artificial larynx is one of the options. It is crucial for the nurse to discuss this with the client prior to the surgery to ensure they understand the use and benefits of this device for communication post-surgery.
A: Scheduling a support session is important but not the priority at this stage.
B: Determining the client's reading ability is not as urgent as ensuring they have a means of communication after the laryngectomy.
D: Explaining esophageal speech is important, but reviewing the artificial larynx is more immediate and essential for communication.
Extract:
Exibit 1
Provider Prescriptions
Day 4, 1500:
Discharge prescriptions:
Cephalexin 500 mg PO every 6 hr for 5 days Prednisone 40 mg PO daily for 5 days Home oxygen 3 L/min via nasal cannula
Exibit 2
Vital Signs
Day 1, 1100:
Temperature 39.1° C (102.4° F) Pulse rate 102/min Respiratory rate 26/min
Blood pressure 122/80 mm Hg Oxygen saturation 86% on room air Weight 90.7 kg (200 lb)
Day 2, 1200:
Temperature 38° C (100.4° F) Pulse rate 100/min Respiratory rate 22/min
Blood pressure 120/74 mm Hg
Oxygen saturation 88% on nasal cannula at 2 L/min Day 3, 1200:
Température 37.2° C (98.9" F) Pulse rate 90/min
Respiratory rate 20/min
Blood pressure 120/72 mm Hg
Exibit 3
Medication Administration Record
Day 1, 1500:
Cefazolin 500 mg every 12 hr IV Dexamethasone 15 mg every 6 hr IV Day 3, 1200:
Discontinue dexamethasone 15 mg every 6 hr IV Prednisone 40 mg PO daily
Day 4, 1500:
Discontinue cefazolin 500 mg every 12 hr IV
Question 5 of 5
A nurse is caring for a client who has pneumonia. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct Answer: D,E,F
Rationale:
Correct Answer: D, E, F
Rationale:
D: Steroid medication should be taken in the morning - Steroid medication is typically taken in the morning to align with the body's natural cortisol production.
E: The steroid dose will decrease each day - Steroid therapy is usually tapered off gradually to prevent withdrawal symptoms.
F: Ensure the oxygen delivery system is at least 8 feet from any heat source - This is important to prevent the risk of fire or explosion.
Incorrect
Choices:
A: Store the oxygen cylinder wrench with the oxygen tank - This is incorrect as the wrench should be stored separately for easy access during emergencies.
B: Antibiotic therapy should be taken for 10 days - The duration of antibiotic therapy may vary depending on the specific antibiotic and the severity of the infection. It is not always 10 days.
C: Adjust the oxygen flow rate as needed to ease breathing - The oxygen flow rate should be set according to the healthcare provider's instructions and not adjusted arbitrarily.
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