ATI LPN
ATI PN Adult Medical Surgical 2019 Questions
Question 1 of 5
A client with chronic obstructive pulmonary disease (COPD) is experiencing respiratory distress. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: The correct answer is to position the client in a high Fowler's position first. This helps improve lung expansion and oxygenation, making it the priority intervention for a client with respiratory distress. Administering bronchodilators or obtaining an ABG sample can wait until the client's oxygenation is improved. Pursed-lip breathing can be helpful, but positioning is more critical in this situation.
Question 2 of 5
A client with a history of diabetes mellitus presents with confusion, sweating, and palpitations. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is A: Check the client's blood glucose level. The client's symptoms are indicative of hypoglycemia, which is a common complication in diabetes mellitus. Checking the blood glucose level will confirm the diagnosis and guide appropriate interventions. Administering insulin (B) could worsen the hypoglycemia. Giving a high-protein snack (C) may help raise blood sugar levels but should be done after confirming the diagnosis. Measuring blood pressure (D) is not the priority in this situation.
Question 3 of 5
A client with heart failure is prescribed digoxin (Lanoxin). Which sign of digoxin toxicity should the nurse teach the client to report?
Correct Answer: B
Rationale: The correct answer is B: Yellow or blurred vision. Digoxin toxicity can lead to visual disturbances, such as yellow or blurred vision, due to its effects on the optic nerve. The nurse should teach the client to report this symptom immediately as it indicates a serious adverse effect. Increased appetite (A), weight gain (C), and nasal congestion (D) are not specific signs of digoxin toxicity and are more commonly associated with other health conditions or side effects of medications. It is crucial for the nurse to emphasize the importance of monitoring and reporting any visual changes to prevent serious complications from digoxin toxicity.
Question 4 of 5
The client has undergone a thyroidectomy, and the nurse is providing care. Which assessment finding requires immediate intervention?
Correct Answer: C
Rationale: The correct answer is C: Numbness and tingling around the mouth. This finding indicates potential hypocalcemia, a common complication post-thyroidectomy due to inadvertent damage to parathyroid glands. Hypocalcemia can lead to tetany, seizures, and cardiac dysrhythmias. Immediate intervention is needed to prevent serious complications. Hoarseness and a sore throat (A) are expected post-thyroidectomy due to intubation. Difficulty swallowing (B) can be due to swelling but is not immediately life-threatening. A temperature of 100.2°F (37.9°C) (D) is slightly elevated but not a priority in this scenario.
Question 5 of 5
A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to assess the effectiveness of the therapy?
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). The aPTT measures the effectiveness of heparin therapy by assessing the clotting time. In patients with DVT receiving heparin, the goal is to keep the aPTT within a therapeutic range to prevent clot formation. Monitoring aPTT helps ensure the dose of heparin is appropriate. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to monitor for heparin-induced thrombocytopenia but does not directly assess the effectiveness of heparin therapy for DVT.