ATI LPN
ATI Adult Medical Surgical Questions
Question 1 of 5
While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding?
Correct Answer: C
Rationale: The correct answer is C: Observe the appearance of the skin on the client's legs. In clients with diabetes mellitus, poor circulation can lead to decreased hair growth on the legs. By observing the skin appearance, the nurse can look for signs of poor circulation such as dry skin, thinning of the skin, or discoloration. This assessment provides further data to support the finding of absent hair growth. Choices A, B, and D are incorrect because they do not directly relate to the assessment of absent hair growth in clients with diabetes mellitus. Palpating for femoral pulses assesses circulation but does not specifically address the absence of hair growth. Assessing for Homan's sign evaluates for deep vein thrombosis, which is not directly related to hair growth. Watching posture and balance during ambulation assesses mobility and stability but does not provide information on hair growth or circulation in the legs.
Question 2 of 5
While assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse notes her deep tendon reflexes are 1+, respiratory rate is 12 breaths/minute, urinary output is 90 ml in 4 hours, and magnesium sulfate level is 9 mg/dl. What intervention should the nurse implement based on these findings?
Correct Answer: C
Rationale: The correct answer is C: Stop the magnesium sulfate infusion immediately. The client is showing signs of magnesium toxicity, as evidenced by decreased deep tendon reflexes, bradypnea (respiratory rate of 12 breaths/minute), oliguria (urinary output of 90 ml in 4 hours), and elevated magnesium sulfate level of 9 mg/dl. Stopping the infusion is crucial to prevent further complications such as respiratory depression, cardiac arrest, and central nervous system depression. Continuing the infusion (choice A) would worsen the toxicity. Decreasing the infusion (choice B) may not be sufficient to address the toxicity. Administering calcium gluconate (choice D) is not the immediate priority; stopping the magnesium sulfate infusion is essential to prevent further harm.
Question 3 of 5
A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective?
Correct Answer: A
Rationale: The correct answer is A because the neuromuscular blocker tubocurarine chloride causes muscle paralysis, leading to the extremities being paralyzed. This indicates that the medication is effectively blocking neuromuscular transmission. B: Twitching with peripheral nerve stimulation indicates incomplete blockade. C: Clenching fist upon command indicates preserved muscle strength. D: Glasgow Coma Scale measures level of consciousness, not neuromuscular blockade.
Question 4 of 5
An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client's comment, what previous lab values should the nurse compare with today's lab report?
Correct Answer: B
Rationale: The correct answer is B. The nurse should look for an increase in today's LDH compared to the previous one to assess for possible liver damage. Acetaminophen overdose can lead to liver toxicity, which can be indicated by elevated LDH levels. LDH is an enzyme released during liver damage. Checking for LDH levels can help assess the impact of increased acetaminophen doses on the liver. Choices A, C, and D are incorrect: A: Looking at hemoglobin and hematocrit is not directly related to acetaminophen use for joint pain. It does not provide information about liver damage. C: APTT measures blood clotting time and is not directly affected by acetaminophen use for joint pain. It does not provide information about liver damage. D: Serum potassium levels are not typically affected by acetaminophen use for joint pain. It does not provide information about liver damage.
Question 5 of 5
Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement?
Correct Answer: C
Rationale: The correct answer is C: Notify the healthcare provider if the child complains of ringing in the ears. This is important because ringing in the ears can be a sign of salicylate toxicity, a potential side effect of aspirin use in children with rheumatic fever. It is crucial to monitor for this symptom to prevent serious complications. A: Instructing the parents to hold the aspirin until the child has a tepid sponge bath is not the most important intervention. Managing salicylate toxicity takes precedence over comfort measures. B: Administering the aspirin with at least two ounces of water or juice is a general guideline for medication administration but not the most critical intervention in this scenario. D: Advising the parents to question the child about seeing yellow halos around objects is not directly related to the potential side effects of aspirin in this case. Monitoring for salicylate toxicity through symptoms like ringing in the ears is more crucial.