ATI LPN
ATI PN Adult Medical Surgical 2019 Questions
Question 1 of 5
The nurse is caring for a client with a spinal cord injury. Which intervention should the nurse implement to prevent autonomic dysreflexia?
Correct Answer: C
Rationale: The correct answer is C: Ensure the client's bladder is emptied regularly. Autonomic dysreflexia is a potentially life-threatening condition that occurs in clients with spinal cord injuries. It is triggered by a distended bladder or bowel. By regularly emptying the client's bladder, the nurse can prevent the stimulus that leads to autonomic dysreflexia. Option A is incorrect because restricting fluid intake can lead to dehydration, exacerbating the condition. Option B is incorrect as temperature regulation is not directly related to preventing autonomic dysreflexia. Option D is incorrect as high-fiber foods do not play a role in triggering this condition.
Question 2 of 5
A client with cirrhosis of the liver is experiencing pruritus. Which intervention should the nurse implement to help relieve the client's symptoms?
Correct Answer: B
Rationale: The correct answer is B: Apply lotion to the skin. Pruritus in cirrhosis is often due to dry skin. Applying lotion helps hydrate the skin, reducing itching. Acetaminophen (A) can worsen liver damage. High-protein diet (C) is not directly related to pruritus relief. Warm bath (D) may further dry the skin.
Question 3 of 5
A client with chronic kidney disease is prescribed a low-protein diet. Which laboratory result should the nurse monitor to evaluate the effectiveness of the diet?
Correct Answer: A
Rationale: The correct answer is A: Blood urea nitrogen (BUN). BUN is a waste product that reflects protein intake and kidney function. In chronic kidney disease, high protein intake can increase BUN levels, so monitoring BUN helps assess the effectiveness of the low-protein diet. Incorrect choices: B: Serum potassium - This is more related to kidney function but not specifically affected by a low-protein diet. C: Serum calcium - Calcium levels are not directly affected by protein intake or a low-protein diet in chronic kidney disease. D: Creatinine clearance - This measures kidney function but is not directly influenced by protein intake.
Question 4 of 5
The client has been prescribed metformin (Glucophage) for type 2 diabetes. Which instruction should the nurse include in discharge teaching?
Correct Answer: B
Rationale: The correct answer is B: Take the medication with meals. Metformin is typically taken with meals to minimize gastrointestinal side effects. Food helps in the absorption and tolerance of the medication. Taking it on an empty stomach can lead to stomach upset. Taking it at bedtime may also cause nighttime disruptions. Taking it as needed for high blood sugar is not appropriate as metformin is usually taken regularly to control blood sugar levels.
Question 5 of 5
A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory test should the nurse monitor to determine the effectiveness of the medication?
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT) and international normalized ratio (INR). Warfarin works by inhibiting vitamin K-dependent clotting factors, affecting the PT and INR. Monitoring these levels helps assess the effectiveness of warfarin in preventing clot formation. Platelet count (A) assesses clotting ability but not the effectiveness of warfarin. Activated partial thromboplastin time (C) assesses intrinsic pathway clotting factors, not affected by warfarin. Fibrinogen level (D) assesses the final step of clot formation, not specific to warfarin effectiveness.