ATI LPN
ATI Adult Medical Surgical Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Diminished cough effort. In myasthenia gravis, muscle weakness can affect the muscles involved in coughing, leading to diminished cough effort. This can result in ineffective airway clearance, putting the client at high risk for respiratory complications. Pain during coughing (choice A) may occur but is not the primary cause of ineffective airway clearance in myasthenia gravis. Thick, dry secretions (choice C) and excessive inflammation (choice D) may contribute to airway clearance issues but are not as directly related to the underlying muscle weakness seen in myasthenia gravis.
Question 5 of 5
Following a CVA, the nurse assesses that a client has developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?
Correct Answer: A
Rationale: The correct answer is A: Continuous tube feeding at 65 ml/hr via gastrostomy. After a CVA, dysphagia, hypoactive bowel sounds, and a firm, distended abdomen indicate a risk for aspiration and bowel obstruction. Continuous tube feeding may worsen these issues. Option B provides nutrition intravenously, bypassing the gastrointestinal tract. Option C helps decompress the stomach. Option D is a medication to help with GI motility. Therefore, the nurse should question option A due to the risk of complications post-CVA.