ATI LPN
ATI Adult Medical Surgical Questions
Question 1 of 5
When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client's vital signs are within normal limits. He reports feeling 'out of breath' but denies any other complaints. What action should the nurse take at this time?
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to decrease the intravenous flow rate of the PRBC transfusion. The client is showing early signs of a transfusion reaction, as evidenced by feeling 'out of breath'. By decreasing the flow rate of the transfusion, the nurse can slow down the rate at which the remaining blood is infused, potentially preventing a more severe reaction. Administering diphenhydramine or albuterol would not address the underlying issue of a potential transfusion reaction. Starting normal saline at the same rate may exacerbate the client's symptoms and is not indicated in this scenario.
Question 2 of 5
A client is being discharged with a new prescription for enoxaparin (Lovenox). Which instruction should the nurse include?
Correct Answer: B
Rationale: The correct answer is B because expelling the air bubble from the syringe before injection helps ensure accurate dosage delivery and prevents air from being injected into the patient. Administering the injection in the thigh (
A) is incorrect as enoxaparin is typically given in the abdomen. Massaging the injection site (
C) can cause bruising or hematoma formation. Alternating injection sites between arms (
D) is not relevant as enoxaparin is usually given in the abdomen.
Question 3 of 5
A patient with type 1 diabetes is prescribed insulin glargine. What is the primary characteristic of this insulin?
Correct Answer: C
Rationale: Insulin glargine is a long-acting insulin due to its slow and consistent release, providing basal insulin coverage for about 24 hours. This steady release mimics the body's natural basal insulin secretion pattern. Rapid-acting insulins (
A) work quickly to control postprandial glucose levels. Intermediate-acting insulins (
B) have a slower onset and last for a moderate duration. Short-acting insulins (
D) act quickly but have a shorter duration of action compared to long-acting insulins.
Question 4 of 5
The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Diminished cough effort. In myasthenia gravis, muscle weakness can affect the muscles involved in coughing, leading to diminished cough effort. This can result in ineffective airway clearance, putting the client at high risk for respiratory complications. Pain during coughing (choice
A) may occur but is not the primary cause of ineffective airway clearance in myasthenia gravis. Thick, dry secretions (choice
C) and excessive inflammation (choice
D) may contribute to airway clearance issues but are not as directly related to the underlying muscle weakness seen in myasthenia gravis.
Question 5 of 5
The nurse formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Diminished cough effort. In myasthenia gravis, muscle weakness can affect the respiratory muscles, leading to ineffective coughing and clearance of airways. Diminished cough effort can result in ineffective airway clearance, putting the client at high risk for respiratory complications.
A: Pain when coughing is not the primary etiology for ineffective airway clearance in myasthenia gravis.
C: Thick, dry secretions may contribute to airway clearance issues but are not the most likely etiology compared to diminished cough effort.
D: Excessive inflammation is not typically associated with ineffective airway clearance in myasthenia gravis.