ATI LPN
ATI Adult Medical Surgical Questions
Question 1 of 5
A client with peptic ulcer disease is prescribed ranitidine (Zantac). Which statement by the client indicates the need for further teaching?
Correct Answer: C
Rationale: Rationale: C is the correct answer. Ranitidine is usually taken on an empty stomach to maximize its effectiveness in reducing stomach acid production. Therefore, taking it with meals would decrease its efficacy. A, B, and D are incorrect because taking ranitidine at bedtime is common practice, smoking can worsen ulcer symptoms, and ranitidine does indeed reduce stomach acid.
Question 2 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.
Question 3 of 5
When should the charge nurse intervene based on the observed behavior?
Correct Answer: B
Rationale: The correct answer is B because it violates patient confidentiality. Reading a client's history and physical in a public area breaches the client's privacy rights. The other choices do not directly compromise patient confidentiality. A involves discussing a cure for AIDS, which is not a breach of confidentiality. C involves sharing personal experiences with the client, and D involves discussing a client's history of drug abuse in a visitor's lounge, which may not be overheard by the client or staff directly involved in the client's care.
Question 4 of 5
The charge nurse observes that a client with a nasogastric tube on low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel (UAP) left the room. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Remove the glass of water and speak to the UAP. The rationale is as follows: 1) Drinking water with low intermittent suction can cause complications. 2) Immediate action is necessary to prevent harm. 3) Speaking to the UAP clarifies the situation and provides education. 4) Removing the glass of water ensures the client's safety. Incorrect choices: B: Discussing at the end of the day delays action and puts the client at risk. C: Writing an incident report is important, but immediate intervention is needed first. D: Reminding the client of electrolyte imbalance does not address the current issue of drinking water with a nasogastric tube.
Question 5 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.