ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
A patient diagnosed with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is the most therapeutic?
Correct Answer: D
Rationale: Your disease doesn't send enough oxygen to your fingertips': Chronic hypoxia in COPD leads to increased capillary growth and tissue changes, resulting in clubbing of the fingers. This response is accurate and appropriately explains the cause. 'Your disease often makes patients lose mental status': While severe hypoxia can cause confusion, this response does not address the reason for clubbing and lacks therapeutic communication. 'Your disease will be helped if you pursed-lip breathe': Pursed-lip breathing helps with air trapping and exhalation in COPD, but it does not explain clubbing of the fingers. 'Your disease affects both your lungs and your heart, and not enough blood is being pumped': COPD primarily affects oxygen exchange in the lungs, not necessarily blood pumping from the heart. Clubbing is due to chronic hypoxia, not poor cardiac output.
Question 2 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 3 of 5
The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage.
Correct Answer: A
Rationale: Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation). Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed. Do nothing as long as the evacuator is compressed: Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection. Chart the results on the intake and output flow sheet: While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.
Question 4 of 5
Your patient drunk 150 mL of Ice Tea. How many ounces is this?
Correct Answer: 5
Rationale: Solution: 1 ounce = 30 mL, so 150 mL ÷ 30 mL/oz = 5 oz. Answer: 5 ounces.
Question 5 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.