ATI RN
ATI RN Adult Medical Surgical 2019 with NGN Questions
Question 1 of 5
A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?
Correct Answer: B
Rationale: Rifampin commonly causes a harmless red-orange discoloration of body fluids, including saliva, urine, and tears, as an expected side effect. This does not indicate toxicity or require a change in medication or increased fluid intake.
Question 2 of 5
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: A monthly calendar helps orient the client to time, reducing confusion in Alzheimer's disease. Covering outlets with tape poses a fire hazard, a dark bedroom increases fall risk, and while a large-face clock may help, a calendar is more effective for orientation.
Question 3 of 5
A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?
Correct Answer: A
Rationale: Clostridium difficile is highly contagious and requires a protective environment to prevent spread. Chlorhexidine and alcohol-based hand rubs are not effective against its spores, and while gloves are used, a protective environment is the priority.
Question 4 of 5
A nurse is providing discharge teaching for a client who has osteomyelitis in the left leg. Which of the following findings should the nurse identify as requiring a referral?
Correct Answer: B
Rationale: Long-term IV antibiotic therapy for osteomyelitis requires referral to prevent complications like peripheral thrombophlebitis. Elevated WBC is expected, furosemide is unrelated, and a HbA1c of 6% indicates good glycemic control.
Question 5 of 5
A nurse is assessing a client who has increased intracranial pressure (ICP). The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
Correct Answer: C
Rationale: Altered level of consciousness is the earliest and most sensitive sign of increased ICP, detectable via the Glasgow Coma Scale. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs indicating severe brainstem involvement.