ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 43 Questions
Question 1 of 5
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?
Correct Answer: C
Rationale: Fingolimod (Gilenya) can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not typical adverse effects of this medication.
Question 2 of 5
A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's complication? (Select all that apply.)
Correct Answer: B,D,F
Rationale: For a flaccid bowel due to a lower motor neuron injury, a bowel program including a high-fluid and high-fiber diet, stool softeners, and manual disimpaction if needed is effective. Pouring warm water, daily enemas, and abdominal massage are not appropriate.
Question 3 of 5
A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
Correct Answer: C,D,E
Rationale: Incisional bulging, clear drainage (possible CSF leak), and severe headache are emergencies post-laminectomy. Surgical discomfort and redness/itching are normal and not urgent.
Question 4 of 5
A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test?
Correct Answer: A
Rationale: Screening for metal implants or devices is critical before an MRI to prevent harm due to magnetic fields. NPO status, sedation, and bladder emptying are not typically required unless specified.
Question 5 of 5
A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
Correct Answer: C
Rationale: The client is manifesting symptoms of autonomic dysreflexia, likely due to bladder distention. Palpating the bladder to check for distention is the first step to identify and address the cause. The other actions are not appropriate as initial responses.