ATI RN
ATI RN Pharmacology 2019 III Questions
Extract:
Question 1 of 5
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Correct Answer: B
Rationale: The correct answer is B: The client opens his eyes when spoken to. This is because a GCS score of 3 for eye opening indicates that the client opens eyes only in response to voice. The other choices are incorrect because a GCS score of 5 for best verbal response and 5 for best motor response suggest that the client is not completely unresponsive or unable to make vocal sounds (
Choice
A), unconscious (
Choice
C), or unable to follow simple motor commands (
Choice
D). It's important to interpret the GCS score accurately to determine the client's level of consciousness and responsiveness.
Question 2 of 5
A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?
Correct Answer: C
Rationale: The correct answer is C: Incorporate nonverbal cues in the conversation. This is appropriate because individuals with aphasia may have difficulty understanding and producing speech but can often interpret nonverbal communication effectively. Nonverbal cues such as gestures, facial expressions, and body language can help enhance communication and convey meaning. Using simple childlike statements (
A) may come across as patronizing and disrespectful. Using a higher-pitched tone of voice (
B) may not necessarily aid in communication for someone with aphasia. Asking multiple choice questions (
D) may not be effective as it may still rely heavily on verbal language.
Question 3 of 5
A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has expanded?
Correct Answer: A
Rationale:
Correct
Answer: A - No fluctuations in the water seal chamber
Rationale: When the lung has fully expanded, there should be no air leaking from the lung into the pleural space, leading to no fluctuations in the water seal chamber. This indicates that the chest tube is effectively removing air or fluid from the pleural space, allowing the lung to fully expand and preventing further collapse.
Summary of other choices:
B: No reports of pleuritic chest pain - This finding does not directly indicate lung expansion, as pain can be present even with an expanded lung.
C: Occasional bubbling in the water seal chamber - Bubbling indicates air leakage, which is not indicative of lung expansion.
D: Oxygen saturation of 95% - While oxygen saturation is important, it does not directly assess lung expansion status.
Question 4 of 5
A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
Correct Answer: C
Rationale:
Correct
Answer: C
Rationale:
1. Synthetic clothing and woolen socks generate static electricity, which can lead to potential oxygen tank explosions.
2. Static electricity can be generated when synthetic fabrics rub against each other or woolen socks rub against synthetic carpet.
3. This practice is unsafe and poses a significant risk to the client's safety.
4.
Therefore, the nurse should identify this statement as needing further teaching to prevent a hazardous situation.
Summary of Incorrect
Choices:
A. Incorrect - The client should not rely on visual cues to determine oxygen flow. It is essential to use a flowmeter for accurate monitoring.
B. Incorrect - Difficulty concentrating may indicate hypoxemia, a potential complication of oxygen therapy. The client should be educated to report this symptom promptly.
D. Incorrect - It is appropriate for visitors to smoke outside to prevent the client's exposure to secondhand smoke, which can be harmful.
E. Incorrect
F. Incorrect
G. Incorrect
Question 5 of 5
A nurse is caring for an older adult client who has a terminal illness and is ventilator dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles?
Correct Answer: D
Rationale:
Correct
Answer: D (Autonomy)
Rationale: Autonomy is the ethical principle that respects an individual's right to make their own decisions regarding their care. In this scenario, the client, who is alert and oriented, has expressed their wish to discontinue the ventilator. Continuing treatment against the client's wishes would violate their autonomy by not honoring their decision-making capacity.
Summary:
A: Justice - Not relevant to the situation as it pertains to fairness and equal treatment.
B: Veracity - Not relevant to the situation as it pertains to truth-telling.
C: Fidelity - Not relevant to the situation as it pertains to loyalty and honoring commitments.