ATI LPN
Adult Medical Surgical ATI Questions
Question 1 of 5
The healthcare provider is preparing to administer a blood transfusion. Which action is most important to ensure client safety?
Correct Answer: B
Rationale: The correct answer is B: Verify the client's identity and blood compatibility. This step is crucial to prevent transfusion reactions due to compatibility issues. By confirming the client's identity and ensuring that the blood type matches, the healthcare provider minimizes the risk of adverse reactions such as hemolytic transfusion reactions. Checking vital signs (A) is important but ensuring blood compatibility takes precedence. Administering blood with normal saline (C) is incorrect as blood should be infused with the appropriate blood administration set. Monitoring the client for the first 15 minutes (D) is essential but verification of identity and blood compatibility is the primary step to prioritize safety.
Question 2 of 5
A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). Which instruction should the nurse provide?
Correct Answer: C
Rationale: The correct answer is C: Use a soft-bristled toothbrush. Patients on warfarin are at risk for bleeding due to its anticoagulant effect. Using a soft-bristled toothbrush helps prevent gum bleeding and injury to the gums, reducing the risk of bleeding complications. Avoiding green leafy vegetables (choice A) is not necessary, as consistent intake is key for warfarin dosing. Taking aspirin (choice B) can increase the risk of bleeding. Limiting fluid intake (choice D) is not indicated in this case.
Question 3 of 5
When teaching a client postoperative breathing techniques with an incentive spirometer (IS), what should the nurse encourage the client to do to maintain sustained maximal inspiration?
Correct Answer: B
Rationale: The correct answer is B: Inspire deeply and slowly over 3 to 5 seconds. This technique is recommended for using an incentive spirometer (IS) to maintain sustained maximal inspiration. Slow, deep inhalation helps fully expand the lungs and improve lung function postoperatively. A: Exhaling forcefully into the tubing is incorrect because the purpose of using an IS is to promote deep inhalation, not forceful exhalation. C: Breathing into the spirometer using normal breath volumes is incorrect as it does not promote maximal inspiration and may not fully expand the lungs. D: Performing IS breathing exercises every 6 hours is incorrect as regular, consistent practice throughout the day is recommended for optimal lung recovery.
Question 4 of 5
An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client?
Correct Answer: C
Rationale: The correct answer is C: Presbycusis. This age-related condition refers to gradual hearing loss typically seen in older adults. In this case, the client's complaint of people whispering and mumbling suggests difficulty hearing clearly, which aligns with symptoms of presbycusis. Delirium (choice A) is characterized by acute confusion and disorientation, not specifically related to hearing loss. Presbyopia (choice B) is a condition of aging that affects near vision, not hearing. Cerebral dysfunction (choice D) refers to broader cognitive impairment, not specifically related to hearing loss as in presbycusis. Therefore, choice C is the most likely age-related condition in this scenario.
Question 5 of 5
A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What intervention can the nurse expect the healthcare provider to prescribe?
Correct Answer: C
Rationale: The correct answer is C: Kayexalate retention enema. In acute renal failure with high serum potassium levels, the priority is to lower potassium levels to prevent cardiac complications. Kayexalate works by exchanging sodium ions for potassium ions in the intestines, promoting potassium excretion in the feces. This intervention helps reduce serum potassium levels quickly. A: Nitrofurantoin is an antibiotic used to treat urinary tract infections, unrelated to managing hyperkalemia. B: Erythropoietin is a hormone used to stimulate red blood cell production, not indicated for reducing potassium levels. D: Azathioprine is an immunosuppressant used for various conditions like autoimmune diseases, not for managing hyperkalemia. In summary, the correct intervention is to administer a Kayexalate retention enema to lower serum potassium levels effectively in acute renal failure. Other options are not appropriate for managing hyperkalemia.