ATI LPN
ATI Adult Medical Surgical Questions
Question 1 of 5
Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement?
Correct Answer: C
Rationale: The correct answer is C: Notify the healthcare provider if the child complains of ringing in the ears. This is important because ringing in the ears can be a sign of salicylate toxicity, a potential side effect of aspirin use in children with rheumatic fever. It is crucial to monitor for this symptom to prevent serious complications. A: Instructing the parents to hold the aspirin until the child has a tepid sponge bath is not the most important intervention. Managing salicylate toxicity takes precedence over comfort measures. B: Administering the aspirin with at least two ounces of water or juice is a general guideline for medication administration but not the most critical intervention in this scenario. D: Advising the parents to question the child about seeing yellow halos around objects is not directly related to the potential side effects of aspirin in this case. Monitoring for salicylate toxicity through symptoms like ringing in the ears is more crucial.
Question 2 of 5
When covering another nurse's assignment during a lunch break, based on the status report provided, which client should the charge nurse check first?
Correct Answer: D
Rationale: The correct answer is D because a pneumothorax with a pulse oximeter reading of 90% indicates potential respiratory compromise, requiring immediate attention to prevent further deterioration. A pneumothorax can lead to decreased oxygenation, which is critical for the client's health and needs prompt intervention. Checking this client first is essential to ensure timely management and prevent any adverse outcomes. Choice A is incorrect because a blood glucose level of 195 mg/dl in a client with diabetic ketoacidosis, while elevated, does not pose an immediate threat to life compared to respiratory compromise. Choice B is incorrect as a scant amount of blood in the drainage pouch does not indicate an urgent situation or immediate risk to the client's health. Choice C is incorrect as serosanguinous drainage in a chest tube post-triple coronary bypass, while requiring monitoring, does not indicate an immediate need for intervention compared to a potential respiratory compromise in choice D.
Question 3 of 5
An outcome for treatment of peripheral vascular disease is, 'The client will have decreased venous congestion.' What client behavior would indicate to the nurse that this outcome has been met?
Correct Answer: A
Rationale: The correct answer is A because avoiding prolonged sitting or standing helps improve venous return by preventing blood from pooling in the legs, reducing venous congestion. This behavior promotes circulation and decreases the risk of complications. Choices B, C, and D do not directly address venous congestion or circulation improvement, making them incorrect options. Avoiding trauma and irritation to the skin (B) is important for skin integrity but not specifically for venous congestion. Wearing protective shoes (C) is related to preventing foot injuries but does not directly impact venous congestion. Quitting smoking (D) is beneficial for overall health but does not directly target venous congestion.
Question 4 of 5
After performing a paracentesis on a client with ascites, 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?
Correct Answer: D
Rationale: The correct answer is D: Vital signs. After paracentesis, monitoring vital signs is crucial as fluid removal can lead to changes in blood pressure, heart rate, and overall fluid balance. Hypotension or tachycardia may indicate hypovolemia or shock. Pedal pulses (A) are important but not as critical post-paracentesis. Breath sounds (B) are important for respiratory assessment but not directly related to fluid removal. Gag reflex (C) is unrelated to paracentesis and not a priority post-procedure.
Question 5 of 5
The nurse is administering sevelamer (RenaGel) during lunch to a client with end-stage renal disease (ESRD). The client asks the nurse to bring the medication later. The nurse should describe which action of RenaGel as an explanation for taking it with meals?
Correct Answer: B
Rationale: The correct answer is B. Sevelamer (RenaGel) is a phosphate binder used in ESRD to bind with phosphorus in foods, preventing its absorption in the gastrointestinal tract. This is important as ESRD patients often have high levels of phosphorus in their blood, which can lead to complications like cardiovascular disease. Taking RenaGel with meals ensures that it binds with phosphorus in the food, reducing its absorption. Choice A is incorrect as RenaGel does not prevent indigestion associated with spicy foods. Choice C is incorrect as RenaGel does not promote stomach emptying or prevent gastric reflux. Choice D is incorrect as RenaGel does not buffer hydrochloric acid or prevent gastric erosion.