ATI LPN
ATI Learning System PN Medical Surgical Final Quizlet Questions
Question 1 of 5
The client is receiving intravenous (IV) morphine for pain control. Which assessment finding requires the most immediate intervention?
Correct Answer: D
Rationale: The correct answer is D: Respiratory rate of 8 breaths per minute. A respiratory rate of 8 breaths per minute indicates respiratory depression, a serious side effect of morphine that can lead to respiratory arrest. Immediate intervention is crucial to prevent further complications, such as hypoxia and respiratory failure. Drowsiness, itching, and nausea are common side effects of morphine but are not life-threatening like respiratory depression. Monitoring and managing respiratory status is the top priority to ensure the client's safety and well-being.
Question 2 of 5
The healthcare provider is caring for a client who has just undergone a thyroidectomy. 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 removal of parathyroid glands. Immediate intervention is necessary to prevent severe hypocalcemia symptoms like tetany and seizures. Hoarse voice (A) and difficulty swallowing (B) are expected post-thyroidectomy due to surgical trauma, while sore throat (D) is common from intubation.
Question 3 of 5
The healthcare professional is caring for a client with heart failure who is receiving digoxin (Lanoxin). Which assessment finding requires immediate intervention?
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. This finding requires immediate intervention because digoxin toxicity can present with gastrointestinal symptoms like nausea and vomiting. This can indicate an overdose of digoxin, which can be life-threatening. Prompt action is necessary to prevent further complications. A: Heart rate of 58 beats per minute is within the therapeutic range for digoxin and does not require immediate intervention. C: Blood pressure of 130/80 mm Hg is also within normal limits and does not indicate an urgent issue. D: Shortness of breath can be a symptom of heart failure but is not a direct indication of digoxin toxicity requiring immediate intervention.
Question 4 of 5
A client is admitted with diabetic ketoacidosis (DKA). Which assessment finding requires immediate intervention?
Correct Answer: C
Rationale: Step-by-step rationale: 1. Deep, rapid respirations in DKA indicate Kussmaul respirations, a compensatory mechanism for metabolic acidosis. 2. Immediate intervention is needed to prevent respiratory failure and further acidosis. 3. Administering IV fluids and insulin can help correct acidosis and stabilize breathing. 4. Fruity breath odor (A) and high blood glucose (B) are common in DKA but do not require immediate intervention. 5. Serum potassium of 5.2 mEq/L (D) is slightly elevated but not as urgent as addressing respiratory distress.
Question 5 of 5
A client with a new diagnosis of diabetes mellitus is learning to self-administer insulin. Which instruction should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Rotate injection sites within the same region. This is important to prevent lipohypertrophy and ensure proper insulin absorption. Administering insulin at the same site each time (B) can lead to tissue damage. Storing insulin in the freezer (A) can alter its effectiveness. Shaking the vial vigorously (D) can cause air bubbles and affect insulin dosage accuracy. Rotation of injection sites within the same region is crucial for consistent absorption and preventing complications.