ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record?
Correct Answer: A
Rationale:
Correct
Answer: A - Left-sided heart failure
Rationale:
1. Crackles in lung fields indicate fluid accumulation in the lungs, a common sign of heart failure.
2. Sleeping on multiple pillows helps alleviate difficulty breathing, a symptom of left-sided heart failure due to pulmonary congestion.
3. Left-sided heart failure typically presents with pulmonary symptoms such as crackles and orthopnea.
Summary:
- B: Myocardial ischemia typically presents with chest pain, not crackles in lung fields.
- C: Right-sided heart failure presents with systemic symptoms like peripheral edema and distended neck veins, not crackles in lung fields.
- D: Atrial fibrillation is an arrhythmia and may not directly cause crackles in lung fields.
Question 2 of 5
Convert from Fahrenheit to Celsius: 98.6
Correct Answer: 37
Rationale:
To convert Fahrenheit to Celsius, use the formula: (°F - 32) x 5/9. For 98.6°F, (98.6 - 32) x 5/9 = 66.6 x 5/9 = 37°C.
Therefore, the correct answer is 37. Other choices are incorrect as they do not follow the correct conversion formula.
Question 3 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: The correct answer is A: Give the medication in the morning daily. Montelukast is a leukotriene receptor antagonist used for asthma maintenance therapy. Administering it daily in the morning helps maintain consistent levels in the body, providing optimal control of asthma symptoms throughout the day. Option B is incorrect because montelukast is not a rescue medication and should not be taken specifically before exercise. Option C is incorrect because montelukast granules should be administered as is, without mixing with water. Option D is incorrect as montelukast is not meant to be used as a rescue medication for acute wheezing episodes.
Question 4 of 5
A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?
Correct Answer: A
Rationale:
Correct
Answer: A: Tell the client to blow his/her nose gently before the instillation of the drops.
Rationale: Asking the client to blow their nose gently before administering nasal decongestant drops helps clear excess mucus, improving the effectiveness of the drops. This step ensures better absorption and distribution of the medication.
Summary of other choices:
B: Assisting the client to a side-lying position is not necessary for administering nasal decongestant drops.
C: Holding the dropper 2 cm above the nares may not be accurate for all types of nasal decongestant drops.
D: Instructing the client to stay in the same position for 2 minutes is not crucial for the administration of nasal decongestant drops.
Question 5 of 5
The wound care nurse is monitoring a patient with a stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this in the patient's medical record?
Correct Answer: C
Rationale: The correct answer is C: Healing Stage III Pressure Ulcer. This choice accurately reflects the current status of the wound - it is a stage III pressure ulcer that is in the healing process, with healthy tissue present. Documenting it as a Stage I (choice
A) would be incorrect as it does not reflect the severity of the original injury. Selecting B (Stage III Pressure Ulcer) would also be incorrect since the wound is in the healing stage.
Choice D (Healing Stage II Pressure Ulcer) is incorrect because the wound is actually a stage III ulcer.
Choices E, F, and G are not relevant as they do not describe the specific status of the wound. In summary, choice C is the most accurate representation of the current condition of the wound, acknowledging both the original severity and the ongoing healing process.