ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
The nurse must give a client an intramuscular injection of a medication which is very irritating to the subcutaneous tissues. To attempt to reduce irritation of the tissues which action should the nurse take?
Correct Answer: B
Rationale: The Z-track method prevents leakage of irritating medications into subcutaneous tissues by sealing the needle track reducing irritation and discomfort. Small gauge needles reduce pain not leakage 45-degree angles are for subcutaneous injections and ice does not prevent tissue irritation.
Question 2 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 3 of 5
A client is recently diagnosed with pneumonia. The nurse observes the client sitting upright in the bed and assesses a respiratory rate of 26. The client states I can't catch my breath. Which abbreviation would be used to document this presentation?
Correct Answer: C
Rationale: SOB (shortness of breath) documents the client’s reported breathing difficulty and tachypnea aligning with pneumonia symptoms. R/O (rule out) is for tentative diagnoses S/P (status post) indicates past procedures and DOB (date of birth) is unrelated.
Question 4 of 5
Chest physiotherapy (CPT) is ordered for a client with pneumonia. The nurse knows that the primary purpose of CPT for this client is to:
Correct Answer: C
Rationale: CPT loosens secretions in pneumonia by using percussion and vibration to mobilize mucus clearing airways and improving ventilation. Deeper inhalations and ciliary movement are secondary benefits and CPT does not propel oxygen but aids gas exchange by clearing obstructions.
Question 5 of 5
The nurse knows that teaching about the use of the spirometer incentive is effective when the client seals the lips around the mouthpiece and:
Correct Answer: A
Rationale: Inhaling slowly to raise the ball and holding it promotes lung expansion and prevents atelectasis which is the correct incentive spirometer technique to improve ventilation and prevent postoperative complications. Exhaling or rapid forceful inspiration does not achieve sustained lung expansion and blowing into the device is incorrect as it is designed for inhalation.