ATI LPN
ATI PN Adult Medical Surgical 2019 Questions
Question 1 of 9
A client with severe anemia is being treated with a blood transfusion. Which assessment finding indicates a transfusion reaction?
Correct Answer: B
Rationale: The correct answer is B: Fever and chills. This indicates a transfusion reaction because it is a common symptom of hemolytic reactions, where the body is reacting to incompatible blood. Elevated blood pressure (A) is not typically a sign of a transfusion reaction. Increased urine output (C) is more likely a sign of fluid overload. Bradycardia (D) is not a common symptom of a transfusion reaction. Fever and chills are classic signs of a transfusion reaction due to the body's immune response to the blood transfusion.
Question 2 of 9
During the initial assessment of a client with a history of substance abuse admitted for detoxification, which intervention is most important?
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's physical health status. This is crucial during detoxification as substance withdrawal can lead to serious physical health complications such as seizures or cardiac issues. Assessing physical health status allows for prompt intervention if needed. Obtaining a detailed substance use history (A) can provide valuable information but is not immediate priority during initial assessment. Establishing a trusting nurse-client relationship (B) is important but ensuring physical safety comes first. Determining client's readiness for change (D) is important for long-term treatment planning but not as urgent as assessing physical health status.
Question 3 of 9
A client with left-sided heart failure is experiencing dyspnea and orthopnea. Which position should the nurse place the client in to relieve these symptoms?
Correct Answer: A
Rationale: The correct answer is A: High Fowler's position. Placing the client in a High Fowler's position helps reduce dyspnea and orthopnea by facilitating lung expansion and improving ventilation. In this position, the client's head and chest are elevated at a 90-degree angle, allowing for maximal chest expansion and improved oxygenation. This position also helps reduce the workload on the heart by decreasing venous return, which can help alleviate symptoms of left-sided heart failure. Summary: - A: High Fowler's position is correct as it facilitates lung expansion and improves ventilation. - B: Supine position would not be ideal as it can exacerbate symptoms by increasing pressure on the lungs and heart. - C: Trendelenburg position would worsen symptoms by increasing venous return and fluid overload. - D: Sims' position is used for procedures or to facilitate drainage, not for relieving dyspnea and orthopnea.
Question 4 of 9
A client with a history of chronic alcohol use is admitted with confusion and an unsteady gait. Which deficiency should the nurse suspect?
Correct Answer: A
Rationale: The correct answer is A: Thiamine (Vitamin B1). Chronic alcohol use can lead to thiamine deficiency, causing neurological symptoms like confusion and unsteady gait (Wernicke's encephalopathy). Thiamine is crucial for brain function and alcohol interferes with its absorption. Vitamin B12 (choice B) deficiency can also cause neurological symptoms but is less likely in this case. Folic acid (choice C) deficiency can lead to anemia and neural tube defects, not directly related to the symptoms described. Vitamin D (choice D) deficiency typically presents with bone pain and muscle weakness, not confusion and gait issues.
Question 5 of 9
The healthcare provider is assessing a client with Cushing's syndrome. Which clinical manifestation should the healthcare provider expect to find?
Correct Answer: C
Rationale: The correct answer is C: Moon face and buffalo hump. In Cushing's syndrome, excessive cortisol production leads to characteristic symptoms like moon face (round, puffy face) and buffalo hump (fat accumulation at the back of the neck). This is due to redistribution of fat in the body. Hyperpigmentation (choice A) is seen in Addison's disease, not Cushing's. Hypotension (choice B) is unlikely due to the cortisol-induced sodium retention. Weight loss (choice D) is less common in Cushing's due to the metabolic changes causing weight gain.
Question 6 of 9
A client with a history of chronic heart failure is experiencing severe shortness of breath and has pink, frothy sputum. Which action should the nurse take first?
Correct Answer: B
Rationale: The correct action for the nurse to take first is to place the client in a high Fowler's position (Choice B). This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and improving ventilation. With severe shortness of breath and pink, frothy sputum, the priority is to optimize respiratory function. Administering morphine sulfate (Choice A) may be indicated later for pain and anxiety but is not the immediate priority. Initiating continuous ECG monitoring (Choice C) is important but not as urgent as addressing the respiratory distress. Preparing the client for intubation (Choice D) should be considered if respiratory distress worsens, but initial interventions should focus on improving oxygenation through positioning.
Question 7 of 9
A client with coronary artery disease (CAD) is prescribed atorvastatin (Lipitor). Which laboratory value requires immediate intervention?
Correct Answer: B
Rationale: The correct answer is B: LDL of 200 mg/dL. Elevated LDL levels are a major risk factor for CAD and require immediate intervention. Atorvastatin (Lipitor) is used to lower LDL levels. High LDL contributes to plaque buildup in arteries. A: Total cholesterol of 180 mg/dL is within the normal range and doesn't require immediate intervention. C: Triglycerides of 150 mg/dL are also within the normal range and don't pose an immediate risk. D: HDL of 40 mg/dL is considered low, but it is not as critical as high LDL levels in the context of CAD.
Question 8 of 9
A client who has been receiving treatment for depression with a selective serotonin reuptake inhibitor (SSRI) reports experiencing decreased libido. What is the best response by the nurse?
Correct Answer: B
Rationale: The correct response is B: I will notify your healthcare provider to discuss possible medication changes. This is the best choice because decreased libido is a common side effect of SSRIs that can significantly impact the client's quality of life. Consulting the healthcare provider is crucial to explore alternative treatment options or adjustments to improve the client's symptoms. Choices A, C, and D do not address the underlying issue of decreased libido and are unlikely to provide effective solutions. Choice A only acknowledges the side effect without offering a proactive solution. Choice C is unrelated to the sexual side effect and may not address the client's concerns. Choice D suggests a general lifestyle change that may not directly address the medication side effect. Consulting the healthcare provider for medication adjustments is the most appropriate action to address this specific side effect.
Question 9 of 9
A client with newly diagnosed diabetes mellitus is receiving teaching on foot care. Which instruction should the nurse include?
Correct Answer: C
Rationale: Correct Answer: C - Trim your toenails straight across to prevent ingrown toenails. Rationale: 1. Trimming toenails straight across helps prevent ingrown nails. 2. Ingrown nails can lead to infection, especially risky for diabetics due to poor wound healing. 3. Walking barefoot toughens feet, increasing risk of injury. 4. Soaking in hot water can cause burns or skin damage. 5. Using a heating pad can lead to burns or decreased sensation in feet, increasing injury risk. Summary: Option C is correct as it directly addresses a common issue in diabetic foot care - ingrown toenails. Options A, B, and D pose risks of injury or damage to the feet, which is detrimental for diabetic individuals.