ATI RN
Adult Health Nursing Test Bank Questions
Question 1 of 5
A patient with a history of stroke is prescribed aspirin and clopidogrel for dual antiplatelet therapy. Which nursing intervention is essential for preventing bleeding complications in this patient?
Correct Answer: A
Rationale: The correct answer is A: Administering proton pump inhibitors (PPIs) concomitantly. Aspirin and clopidogrel can increase the risk of gastrointestinal bleeding. PPIs help reduce this risk by decreasing gastric acid production. Therefore, administering PPIs with dual antiplatelet therapy is essential for preventing bleeding complications. Encouraging increased fluid intake (B) may not directly address the risk of bleeding. Monitoring for signs of thrombocytopenia (C) is important but may not directly prevent bleeding in this case. Providing education on fall prevention measures (D) is important for overall safety but does not directly address bleeding risks associated with dual antiplatelet therapy.
Question 2 of 5
A patient is prescribed a selective serotonin reuptake inhibitor (SSRI) for the treatment of depression. Which adverse effect should the nurse monitor closely in the patient?
Correct Answer: C
Rationale: The correct answer is C: Hyponatremia. SSRI medications can lead to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), causing hyponatremia. This occurs due to increased levels of serotonin affecting the hypothalamus, leading to excessive ADH release. Hyponatremia can result in neurological symptoms and must be closely monitored. A: Bradycardia is not a common adverse effect of SSRIs. B: Hyperkalemia is not typically associated with SSRIs. D: Hypertension is not a common adverse effect of SSRIs; they may actually lower blood pressure.
Question 3 of 5
During a surgical procedure, the nurse notices a sudden decrease in the patient's oxygen saturation on the monitor. What immediate action should the nurse take?
Correct Answer: A
Rationale: The correct immediate action is to inform the surgeon and anesthesiologist (Choice A) because a sudden decrease in oxygen saturation during surgery is a critical situation that requires prompt attention from the entire surgical team. The surgeon and anesthesiologist need to be made aware of the situation so that they can assess the patient's condition and make any necessary adjustments to the surgical procedure or anesthesia delivery. Increasing the flow rate of oxygen (Choice B) may help temporarily but does not address the underlying cause of the oxygen desaturation. Checking the endotracheal tube placement (Choice C) is important but may not be the immediate priority in this critical situation. Assessing the patient's respiratory status (Choice D) is important but should be done after informing the surgeon and anesthesiologist to ensure coordinated and timely interventions.
Question 4 of 5
During surgery, the nurse observes a sudden change in the patient's level of consciousness. What is the nurse's immediate action?
Correct Answer: D
Rationale: The correct immediate action for the nurse is to notify the anesthesia provider immediately (Option D). This is crucial because a sudden change in the patient's level of consciousness during surgery could indicate a serious issue related to anesthesia administration. Notifying the anesthesia provider promptly allows for quick assessment and intervention to address the underlying cause, potentially preventing complications or even saving the patient's life. Administering a reversal agent (Option A) without proper evaluation by the anesthesia provider could be dangerous. Documenting the change in the patient's chart (Option B) is important but not the most immediate action. Checking the patient's vital signs (Option C) is also important but may not provide immediate insight into the cause of the change in consciousness.
Question 5 of 5
During surgery, the nurse notices that the patient's blood pressure is trending higher than the baseline. What action should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Notify the anesthesia provider for further assessment. This is the most appropriate action because an anesthesia provider is trained to assess and manage changes in blood pressure during surgery. Administering antihypertensive medication (A) without proper assessment can be dangerous. Documenting the readings (B) is important but not the immediate action. Continuing to monitor closely (D) is necessary but notifying the anesthesia provider for further assessment should be the priority.