ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 31 Questions
Question 1 of 5
A client diagnosed with polycythemia vera has come into the clinic because they have developed a night-time cough, fatigue, and shortness of breath. From these clinical manifestations, what complication would the nurse suspect in this client?
Correct Answer: C
Rationale: The symptoms exhibited by this client are indicative of heart failure. Complications of polycythemia vera include hypertension, heart failure, stroke, tissue and organ infarction, and hemorrhage.
Question 2 of 5
The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?
Correct Answer: C
Rationale: Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Expect iron to color stool dark green or black.
Question 3 of 5
The nurse is caring for four clients on the medical-surgical unit of the hospital. What client is mostly likely to be receiving treatment for sickle cell crisis?
Correct Answer: B
Rationale: Sickle cell disease is a common genetic disorder found primarily in clients of African descent but also in people from Mediterranean and Middle Eastern countries. It is unlikely that a Caucasian male, Native American/First Nations female, or eastern European female will be affected by this disease.
Question 4 of 5
The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be?
Correct Answer: C
Rationale: An expected outcome for the client with hypovolemic anemia is to monitor to detect hypoxemia and manage and minimize inadequate oxygenation. The oxygen saturation should be monitored to measure the percentage of oxygen bound to hemoglobin. The nurse should report a sustained oxygen saturation value below 90%. Give oxygen per nasal cannula or simple mask to maintain oxygen saturation at or above 90%. It is important to administer the oxygen first and then contact the charge nurse to alert them. It is not necessary at this time if the client is not in respiratory distress to intubate the client. Placing the client in the supine position would decrease the oxygen saturation level further.
Question 5 of 5
A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?
Correct Answer: C
Rationale: When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.