ATI LPN
ATI PN Adult Medical Surgical 2019 Questions
Question 1 of 5
When assessing a client with suspected meningitis, which finding is indicative of meningeal irritation?
Correct Answer: D
Rationale: The correct answer is D, Both A and C. Brudzinski's sign and Kernig's sign are both indicative of meningeal irritation. Brudzinski's sign is when flexion of the neck causes involuntary flexion of the hip and knee. Kernig's sign is when there is resistance or pain with knee extension after hip flexion. These signs suggest inflammation of the meninges, commonly seen in meningitis. Babinski reflex (choice B) is not specific to meningitis and is related to upper motor neuron dysfunction. Therefore, the correct answer is D as it includes the two most relevant signs for meningeal irritation, while the other choices are not directly associated with this condition.
Question 2 of 5
A client with chronic renal failure is scheduled to receive epoetin alfa (Epogen). Which laboratory result should the nurse review before administering the medication?
Correct Answer: C
Rationale: The correct answer is C: Hemoglobin level. In chronic renal failure, the kidneys may not produce enough erythropoietin, leading to anemia. Epoetin alfa stimulates red blood cell production. Therefore, reviewing the hemoglobin level is crucial to determine the need for the medication. Incorrect choices: A: Blood urea nitrogen (BUN) and B: Creatinine clearance are indicators of kidney function but not directly related to monitoring the effectiveness of epoetin alfa. D: Serum potassium is important in renal failure but not specifically needed to review before administering epoetin alfa.
Question 3 of 5
What action should the nurse take to prevent tracheal tissue damage in a client with a tracheostomy?
Correct Answer: C
Rationale: The correct action to prevent tracheal tissue damage in a client with a tracheostomy is to use the minimal leak technique when inflating the cuff (Choice C). This technique helps maintain proper cuff pressure, preventing excessive pressure on the tracheal tissue. Securing the tracheostomy ties firmly (Choice A) may cause pressure ulcers on the neck. Changing the tracheostomy tube daily (Choice B) is unnecessary and may introduce infection. Cleaning the stoma with hydrogen peroxide (Choice D) can be too harsh and damaging to the delicate tracheal tissue.
Question 4 of 5
A client with chronic obstructive pulmonary disease (COPD) is experiencing respiratory distress. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: The correct answer is to position the client in a high Fowler's position first. This helps improve lung expansion and oxygenation, making it the priority intervention for a client with respiratory distress. Administering bronchodilators or obtaining an ABG sample can wait until the client's oxygenation is improved. Pursed-lip breathing can be helpful, but positioning is more critical in this situation.
Question 5 of 5
The nurse is caring for a client with hyperthyroidism. Which intervention should the nurse implement to manage the client's condition?
Correct Answer: B
Rationale: The correct answer is B: Encourage frequent rest periods. For a client with hyperthyroidism, rest is crucial to conserve energy and support the body's recovery. Hyperthyroidism is characterized by increased metabolic rate, leading to fatigue and weakness. Rest periods help reduce metabolic demands and prevent exhaustion. A high-calorie diet (choice A) may be necessary to support increased metabolism but is not the priority. Restricting fluid intake (choice C) can lead to dehydration, which should be avoided in hyperthyroidism. Administering a stool softener (choice D) is unrelated to managing hyperthyroidism.