ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A client with acute lymphocytic leukemia received induction chemotherapy. The client's absolute neutrophil count is zero, and the client is experiencing fatigue and mild nausea. Which nursing action is the highest priority?
Correct Answer: B
Rationale: Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
Question 2 of 5
An 82-year-old client who sustained a head injury in a motor vehicle crash while on warfarin therapy is admitted for observation. The nurse is providing teaching regarding the client's diagnosis of a subdural hematoma. Which of the following statements by the client indicates an understanding of teaching?
Correct Answer: C
Rationale: Taking a blood thinner like warfarin increases the risk of bleeding and hematoma formation, particularly when combined with head trauma. This statement correctly links the anticoagulant therapy and head injury as contributing factors to the subdural hematoma.
Question 3 of 5
A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
Question 4 of 5
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which finding should the nurse expect?
Correct Answer: A
Rationale: Clay-colored stools are indicative of a bile duct obstruction because bile is not reaching the intestines, leading to pale or clay-colored stools.
Question 5 of 5
The nurse is caring for a client who has disseminated intravascular coagulation (DIC). The healthcare provider prescribes an infusion of heparin. Based on the protocol, the initial dose is 14 units/kg/hr. The heparin is dispensed at a concentration of 25,000 units/250 ml. The client weighs 79.1 kg. How many mL/hr will the nurse set the Infusion pump? (Round the rate to nearest tenth. Only enter numbers and decimals. Do not enter any letters in your answer.)
Correct Answer: 11.1
Rationale: Infusion rate = 1107.4 units/hr / 100 units/mL = 11.074 mL/hr, rounded to 11.1 mL/hr.