ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has been wearing a nitroglycerin patch and receives an order to start a nitroglycerin intravenous Infusion. The old patch must be removed from the client's body in order to avoid:
Correct Answer: C
Rationale: Removing the nitroglycerin patch prevents overdose as both patch and IV infusion deliver the drug systemically risking excessive vasodilation and hypotension. Skin irritation is a side effect interactions are not primary and patch loss is irrelevant when switching routes.
Question 2 of 5
A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to:
Correct Answer: C,E
Rationale: Hyperkalemia (6.3 mEq/L above normal 3.5-5.0 mEq/L) risks cardiac dysrhythmias and neuromuscular issues requiring immediate assessment for muscle weakness/flaccid paralysis and cardiac monitoring to detect life-threatening arrhythmias. Diluting potassium or encouraging potassium-rich foods worsens hyperkalemia and intake/output monitoring is secondary.
Question 3 of 5
The nurse recognizes that the most appropriate reason to suction a client is that:
Correct Answer: D
Rationale: Suctioning is indicated when the client cannot clear secretions effectively as evidenced by gurgling respirations and inability to cough ensuring airway patency. Routine suctioning every eight hours or hourly without clinical need is inappropriate as it may cause trauma or discomfort. Coughing and swallowing sputum indicates effective airway clearance not requiring suctioning.
Question 4 of 5
The nursing assessment finding that represents the most serious indication of a client's deteriorating oxygenation status is:
Correct Answer: C
Rationale: Cyanosis (bluish skin/mucous membranes) indicates severe oxygenation failure due to inadequate oxygen delivery reflecting critical hypoxia. Pursed-lip breathing is compensatory clubbing is chronic and skin turgor relates to hydration not oxygenation.
Question 5 of 5
The client has had a surgical debridement of a wound which is starting to heal. In order to further promote healing this client should be encouraged to consume a balanced diet with emphasis on increased:
Correct Answer: B
Rationale: Vitamin C is essential for collagen synthesis and wound healing as it supports tissue repair and immune function. Carbohydrates provide energy but are not specific to healing calcium aids bone health and vitamin E’s antioxidant role is less critical for wounds.