ATI RN
ATI Client Comfort and End of Life Care Quizlet Questions
Question 1 of 5
A client asks the nurse why pain medication is given before physical therapy. What would be the basis of the nurse's response?
Correct Answer: D
Rationale: The basis of the nurse's response is to minimize discomfort, as pre-therapy pain medication reduces pain during movement, enabling active participation in physical therapy (e.g., stretching) without distresskey for recovery or chronic pain management. Timing optimizes function. Choice A, prevent drowsiness, is backwardanalgesics may cause it, but that's not the goal here. Choice B, reduce muscle tension, occurs indirectly, but discomfort reduction drives dosing, not just tension relief. Choice C, increase pain tolerance, is vaguemedication lowers pain perception, not tolerance capacity. Choice D is correct, guiding nurses to explain this preemptive strategye.g., taking ibuprofen 30 minutes priorensuring therapy's benefits (mobility) outweigh pain barriers, enhancing outcomes in rehab or chronic care.
Question 2 of 5
The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
Correct Answer: D
Rationale: Chloramphenicol is an antibiotic reserved for serious infections due to its potential for severe toxicity, with bone marrow suppression (Choice D) being the most dangerous adverse reaction. This condition can manifest as aplastic anemia, a potentially fatal reduction in blood cell production, affecting red cells, white cells, and platelets. The risk arises because chloramphenicol inhibits protein synthesis in bone marrow mitochondria, leading to suppressed hematopoiesis. Lethal arrhythmias (Choice A) are not a primary concern with this drug, as it doesn't directly affect cardiac ion channels. Malignant hypertension (Choice B) is unrelated, as chloramphenicol doesn't influence vascular tone or blood pressure significantly. Status epilepticus (Choice C), a prolonged seizure state, is also not associated, as the drug's neurotoxicity is more likely to cause peripheral neuropathy than seizures. Bone marrow suppression can lead to life-threatening infections, bleeding, or anemia, requiring close monitoring (e.g., regular complete blood counts). Its severity and irreversibility in some cases make it the most toxic reaction, confirming Choice D as the correct answer.
Question 3 of 5
While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?
Correct Answer: C
Rationale: Granulation tissue in an open wound indicates healing, with new, red, vascular tissue forming. Moist, sterile saline gauze (Choice C) is most appropriate because it maintains a moist environment, promoting cell migration and preventing desiccation of granulation tissue, which could halt healing. Dry sterile dressing (Choice A) adheres to the wound, damaging granulation tissue upon removal and delaying healing. Sterile petroleum gauze (Choice B) supports healing but is costlier and less practical for interim use, often reserved for specific wounds like burns. Povidone-iodine-soaked gauze (Choice D) is cytotoxic to healing cells, irritating granulation tissue and slowing repair, making it unsuitable. Research supports moist wound healing (e.g., Winter's 1962 study), showing faster epithelialization with moisture. Until the specialist arrives, moist saline gauze balances efficacy, availability, and safety, protecting the delicate healing process. Thus, Choice C is the correct dressing choice.
Question 4 of 5
If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
Correct Answer: B
Rationale: A blood pressure cuff too small for a client's arm compresses the brachial artery excessively, requiring higher inflation pressure to occlude it, resulting in a false-high measurement (Choice B). The cuff's bladder should encircle 80% of the arm; if undersized (e.g., adult cuff on an obese arm), it overestimates systolic and diastolic readingse.g., 150/90 mmHg might read 160/100 mmHg. Failing to show changes (Choice A) isn't the issue; the reading is inaccurate, not unresponsive. Sciatic nerve damage (Choice C) is unrelated, as the sciatic nerve is in the leg, not arm. A false-low measurement (Choice D) occurs with an oversized cuff, the opposite problem. Studies (e.g., AHA guidelines) confirm small cuffs inflate unevenly, skewing results high. Proper sizing prevents misdiagnosis like hypertension, making Choice B the correct effect.
Question 5 of 5
A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it's typically due to:
Correct Answer: D
Rationale: Jugular vein distention (JVD)visible neck vein bulgingindicates elevated central venous pressure, typically from fluid overload (Choice D). This occurs when excess volume (e.g., heart failure, IV overload) backs up into the venous system, distending the jugular veins. Chest pain and shortness of breath align with this, suggesting cardiac strain (e.g., right heart failure). A neck tumor (Choice A) might compress veins, but JVD requires systemic pressure, not local obstruction, and lacks respiratory symptoms. Electrolyte imbalance (Choice B) affects cellular function, not directly venous pressure. Dehydration (Choice C) collapses veins, opposite to JVD. For example, in congestive heart failure, fluid retention raises venous return, causing JVD, detectable at 45° elevation. Fluid overload's pathophysiology fits the presentation, making Choice D the correct cause.