ATI LPN
ATI Adult Medical Surgical Questions
Question 1 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 2 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 3 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.
Question 4 of 5
Which signs or symptoms are characteristic of an adult client diagnosed with Cushing's syndrome?
Correct Answer: D
Rationale: The correct answer is D because central-type obesity with thin extremities is a classic characteristic of Cushing's syndrome due to excess cortisol. This pattern of weight distribution is caused by cortisol's impact on fat metabolism and distribution. A is incorrect because a husky voice and hoarseness are not typical symptoms of Cushing's syndrome. B is incorrect as warm, soft, moist, salmon-colored skin is not a common finding in Cushing's syndrome. C is incorrect because visible swelling of the neck without pain is not a typical sign of Cushing's syndrome.
Question 5 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.