ATI RN
ATI RN pharmacology 2023 Questions
Extract:
Medication Administration Record
Nurses' Notes
Vital Signs
0830:
Morphine 10 mg subcutaneous every 3 hr PRN pain
Question 1 of 5
Click to highlight the documentation in the client's medical record that requires further action by the nurse.
Correct Answer: B,C,D
Rationale:
To select the correct answer, , we must identify concerning signs that require immediate action.
B: A client being difficult to arouse indicates altered consciousness, necessitating urgent attention.
C: A respiratory rate of 10/min is abnormally low and indicates respiratory distress.
D: A pulse oximetry of 88% on room air is below the normal range, indicating hypoxemia.
Incorrect options:
A: Temperature of 37.5°C is within normal range.
E: Pupils being equal and reactive are normal findings.
F: Blood pressure of 99/46 mm Hg is slightly low but not critically concerning.
G: Heart rate of 61/min is within normal limits.
Extract:
Question 2 of 5
A nurse on a medical unit is caring for a group of clients. For which of the following tasks should the nurse wear a face shield?
Correct Answer: A
Rationale: The correct answer is A: Suctioning a client's tracheostomy tube. When suctioning a tracheostomy tube, there is a risk of exposure to the client's respiratory secretions which may contain pathogens. Using a face shield provides protection against potential splashes or sprays of secretions, reducing the risk of contamination.
Choice B (Emptying an indwelling urinary catheter bag) does not require a face shield as it does not involve exposure to respiratory secretions.
Choice C (Inserting an IV catheter for a client who has peritonitis) involves a different type of procedure that does not necessitate a face shield.
Choice D (Changing the brief of an older adult client who has a Clostridium difficile infection) may require additional precautions such as gloves and gown due to the risk of contact transmission, but a face shield is not specifically indicated for this task.
Question 3 of 5
A nurse manager is evaluating a nurse who is performing a urinary catheterization on a male client. Which of the following actions by the nurse demonstrates correct aseptic technique?
Correct Answer: C
Rationale:
Correct Answer: C - Cleanses the meatus from the center in a circular motion.
Rationale:
1. Cleansing the meatus from the center in a circular motion helps to prevent contamination by moving from the least contaminated area to the most contaminated area.
2. This technique minimizes the risk of introducing microorganisms into the urethra during the catheterization procedure.
3. By starting from the center and moving outward, the nurse ensures thorough cleaning of the meatus and reduces the chance of introducing infection.
Incorrect
Choices:
A: Grasping the catheter 10.16 to 12.7 cm (4 to 5 in) from the tip - Incorrect because holding the catheter too close to the tip can lead to contamination.
B: Cleansing the meatus using a clean cotton ball - Incorrect because a cotton ball may leave fibers behind, increasing the risk of infection.
D: Applying clean gloves before beginning the procedure - Incorrect because clean gloves are necessary but do not
Question 4 of 5
A nurse is preparing to obtain a health history from a newly admitted client. Which of the following information should the nurse expect to include?
Correct Answer: C
Rationale: The correct answer is C: Health habits. When obtaining a health history, it is essential for the nurse to gather information about the client's health habits such as diet, exercise, smoking, alcohol consumption, and sleep patterns. This information helps in assessing the client's overall health status, identifying potential risk factors, and developing appropriate care plans. Laboratory results (
A) and physical examination findings (
B) are important components of the assessment but are typically obtained after the health history. Observed client behaviors (
D) are subjective and may not provide a comprehensive understanding of the client's health.
Question 5 of 5
A nurse caring for a client who has a prescription for morphine 5 mg IM accidentally administers the whole 10 mg from the single-dose vial. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Measure the client's respiratory rate. This is the first action the nurse should take because an overdose of morphine can lead to respiratory depression, which is a life-threatening complication. By assessing the client's respiratory rate, the nurse can quickly determine if the client is experiencing any respiratory distress and needs immediate intervention. Reporting the incident to the pharmacy (
A) or completing an incident report (
D) can be done after ensuring the client's safety. Notifying the client's provider (
B) can be important but assessing the respiratory rate takes precedence in this situation.