ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
A nurse is teaching a client who has a new prescription for diphenhydramine for allergic rhinitis. The nurse should instruct the client to monitor for which of the following manifestations as an adverse effect of this medication? (Select all that apply.)
Correct Answer: C,D
Rationale: Urinary retention: Diphenhydramine has anticholinergic effects, which can lead to urinary retention, especially in older adults or those with prostate issues. Dry mouth: Diphenhydramine blocks muscarinic receptors, reducing saliva production and causing dry mouth. Nonproductive cough: Diphenhydramine is an antihistamine, not a cough suppressant. It does not cause a nonproductive cough as a side effect. Drowsiness: First-generation antihistamines (like diphenhydramine) cause CNS depression, leading to drowsiness. Skin rash: Skin rash is not a common adverse effect of diphenhydramine but can be a sign of an allergic reaction.
Question 2 of 5
A patient who has been taking antihypertensive drugs for a few months states that a new, persistent dry cough is very bothersome. The nurse knows that this cough is an adverse effect of which class of antihypertensive drugs?
Correct Answer: C
Rationale: Angiotensin-converting enzyme (ACE) inhibitors: ACE inhibitors (e.g., lisinopril, enalapril) can cause a persistent dry cough due to the accumulation of bradykinin, a substance that can irritate the airways. Calcium channel blocker: Calcium channel blockers (e.g., amlodipine, diltiazem) do not commonly cause a dry cough. They primarily work by relaxing blood vessels and reducing heart workload. Angiotensin II receptor blocker: ARBs (e.g., losartan, valsartan) do not typically cause a persistent cough. They are often prescribed instead of ACE inhibitors for patients who experience this side effect. Beta-blockers: Beta-blockers (e.g., metoprolol, propranolol) are not commonly associated with a dry cough. They mainly affect heart rate and blood pressure but can cause bronchospasms in some patients.
Question 3 of 5
The nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?
Correct Answer: A
Rationale: Respirations: C4 injuries compromise the phrenic nerve, which controls the diaphragm. A high cervical spine injury can lead to respiratory failure, making airway and breathing the top priority. Pulse: While monitoring circulation is important, breathing takes priority in a C4 injury due to the risk of respiratory paralysis. Temperature: Temperature regulation may be affected due to autonomic dysfunction, but airway and breathing remain the priority. Blood Pressure: While spinal cord injuries can cause neurogenic shock (low BP, bradycardia), ensuring airway and breathing comes first.
Question 4 of 5
Which finding will alert the nurse to a potential wound dehiscence?
Correct Answer: A
Rationale: Report by patient that something has given way: A patient reporting a 'giving way' sensation is a classic early sign of dehiscence, indicating that the wound edges are separating. Drainage that is odorous and purulent: Purulent (pus-like) and foul-smelling drainage suggests infection, not necessarily dehiscence. Infection can contribute to dehiscence, but it is not the defining feature. Protrusion of visceral organs through a wound opening: Evisceration occurs when internal organs protrude through the incision. Dehiscence is partial or complete separation of the wound edges without organ protrusion. Chronic drainage of fluid through the incision site: Persistent drainage suggests a fistula (abnormal connection between tissues), infection, or poor wound healing, rather than wound dehiscence.
Question 5 of 5
A nurse on the telemetry(cardiac unit) is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0-10 pain scale. The nurse administers 1 nitroglycerin (sublingual). After 5 minutes, the client states that his chest pain is now a severity of 2. Which of the following actions Should the nurse take?
Correct Answer: C
Rationale: Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.