ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.)
Correct Answer: A,B,D,E
Rationale: Rectal: The rectal route provides a reliable measure of core body temperature because of its proximity to major blood vessels. Urinary Bladder: A temperature-sensing urinary catheter can provide continuous monitoring of core temperature, especially in critical care settings. Esophagus: Esophageal temperature monitoring is used in intubated patients and cardiac surgery patients to measure core temperature accurately. Pulmonary Artery: A pulmonary artery catheter (Swan-Ganz catheter) directly measures blood temperature from the heart, making it the most accurate core temperature measurement. Temporal Artery: While temporal artery thermometers are non-invasive and commonly used, they measure skin temperature, which is not a true core temperature.
Question 2 of 5
A nurse caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide to the client's parents on administering the medication?
Correct Answer: A
Rationale: Give the medication in the morning daily: Montelukast (a leukotriene receptor antagonist) is given once daily in the evening for long-term asthma control. If prescribed for allergic rhinitis, it can be given in the morning. Administer the medication 2 hours before exercise: Montelukast is not a rescue medication but a maintenance drug. However, it can be prescribed for exercise-induced bronchospasm and is taken at least 2 hours before exercise when used for that purpose. Administer the granules mixed with 20 ounces of water: Montelukast granules should be mixed with a small amount of soft food (e.g., applesauce, mashed carrots) or breast milk/formula but not a large volume of liquid. Give the medication at the onset of wheezing: Montelukast is not a quick-relief medication and does not work immediately. Short-acting bronchodilators (e.g., albuterol) should be used for acute wheezing.
Question 3 of 5
Which action should the nurse take when using critical thinking to make clinical decisions?
Correct Answer: D
Rationale: Consider what is important in any given situation: Critical thinking involves analyzing the situation, prioritizing information, and making decisions based on what is most important for patient safety and care. Reads and follows the health care provider's orders: While following provider orders is important, critical thinking requires assessing the situation and considering all relevant factors, rather than just following orders without analysis. Accepts one established way to provide care: Critical thinking involves evaluating different approaches and adapting to individual patient needs rather than rigidly adhering to a single method. Makes decisions based on intuition: While intuition can be helpful, evidence-based practice and clinical reasoning should guide decision-making, not just intuition alone.
Question 4 of 5
A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?
Correct Answer: C
Rationale: Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.
Question 5 of 5
A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?
Correct Answer: D
Rationale: Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.