ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
Correct Answer: A
Rationale:
Correct
Answer: A: Make sure the client's room has positive pressure airflow.
Rationale:
1. Positive pressure airflow prevents contaminated air from entering the room, reducing the risk of infections.
2. It helps maintain a clean environment by keeping airborne pathogens out.
3. Protects the client who has a compromised immune system post-transplant.
Summary of Incorrect
Choices:
B: Disposable utensils are important but do not directly protect the client from airborne infections.
C: N95 respirators are for the healthcare provider's protection, not the client's.
D: Monitoring temperature is essential but does not directly prevent infections in a protective isolation setting.
Question 2 of 5
A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Left-sided heart failure typically results in pulmonary congestion, leading to symptoms like dyspnea due to fluid accumulation in the lungs. Pedal edema (
A) is more common in right-sided heart failure. Enlarged liver (
B) is a sign of right-sided heart failure as well. Neck vein distention (
D) is indicative of right-sided heart failure due to increased right atrial pressure. The focus in left-sided heart failure is on pulmonary symptoms, making dyspnea the most relevant manifestation.
Question 3 of 5
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, and digestion should be minimized to reduce pancreatic enzyme secretion. Keeping the client on NPO status allows the pancreas to rest and reduces stimulation of enzyme production. Administering antihypertensive medications (
A) is not directly related to pancreatitis care. Placing the client in a supine position (
C) may not be comfortable and can exacerbate pain. Monitoring for hypercalcemia (
D) is important in chronic pancreatitis but not typically a priority in acute cases.
Question 4 of 5
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice
A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice
C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice
D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
Question 5 of 5
A nurse is providing discharge teaching to a client who had a bilateral architectomy. The nurse should instruct the client to expect which of the following symptoms?
Correct Answer: A
Rationale: The correct answer is A: Hypoglycemia. After a bilateral adrenalectomy, the client will have decreased cortisol production, leading to adrenal insufficiency. This can result in hypoglycemia due to decreased glucose regulation. Increased libido (
B) and increased muscle mass (
D) are not typical symptoms following this procedure. Hot flashes (
C) are more commonly associated with menopause.