ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 45 Questions
Question 1 of 5
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak and tell his, he has very very heavy. Curently, the clients neurologic examination is normal. About what drug should the nurse plan to teach the client?
Correct Answer: B
Rationale: This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed against to clpolgelgel on discharge. Altephase is used for ischemic stroke. Heparin and mannitol are not used for this condition.
Question 2 of 5
A client is being prepared for a mechanical em/bolectomy. What action by the nurse takes priority?
Correct Answer: B
Rationale: For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibr/olytic/ytes are not used. A neurologic assessment and medication review are important, but the consent is the priority.
Question 3 of 5
A client had is em/bolectomy for an arteri/ovenous malformation (AVM). The client is now reporting a severe headache and has vom/ited. What action by the nurse takes priority?
Correct Answer: C
Rationale: The client may to experiencing a re/hed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team but getting immediate medical attention is the priority. Admin/tering pain medication may not be warranted if the client are the return to emergency. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.
Question 4 of 5
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the de/ocate sodium (Col/ace) because the client had a large stool car/ifier. What action by the supervising nurse is best?
Correct Answer: B
Rationale: A student nurse should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Val/aba's maneuver when cons/ist/ated. The supervising nurse should instruct the student to administer the docuscate. The other options are not appropriate. The medication could be held for diarrhea.
Question 5 of 5
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beat/min, pulse pressure increase from 26 to 40 min $\mathrm{Hg}$, and respiratory irregularities. What action by the nurse takes priority?
Correct Answer: A
Rationale: These manifestations indicate Cushing syndrome, a potentially life-threatening increase in intracranial trauma (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment and pacion medication.