ATI RN
ATI Med Surg N241 Exam Questions
Extract:
Question 1 of 5
A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?
Correct Answer: A
Rationale: Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment. The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia. This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario. While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.
Question 2 of 5
When planning care for a client with acute pancreatitis, which order would the nurse anticipate that will contribute to pain control?
Correct Answer: B
Rationale: Pancreatic enzymes are typically used to aid in digestion rather than pain control in acute pancreatitis. Decompression of the gastrointestinal tract through nasogastric suction can help reduce pancreatic stimulation and alleviate pain in acute pancreatitis. While ambulation may help prevent complications, it is not directly related to pain control in acute pancreatitis. A clear liquid diet may be initiated once the acute phase has resolved, but it does not directly contribute to pain control.
Question 3 of 5
A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?
Correct Answer: B
Rationale: Bowel pattern changes are not typically associated with hepatitis C. Hepatitis C can be transmitted through blood transfusions received before widespread screening for the virus. Travel history is not directly relevant to assessing for hepatitis C transmission. While diabetes can be a comorbidity associated with hepatitis C, it is not a primary assessment question for suspected hepatitis C.
Question 4 of 5
A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?
Correct Answer: A
Rationale: Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding. While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided. Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding. Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.
Question 5 of 5
The nurse is admitting a client with the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?
Correct Answer: B
Rationale: Bradycardia is not typically associated with hepatic encephalopathy. Asterixis is a characteristic finding in hepatic encephalopathy, known as 'flapping tremor,' indicating neuromuscular irritability due to elevated blood ammonia levels. Fever is not a common direct symptom of hepatic encephalopathy. Melena indicates gastrointestinal bleeding, which while possible in liver disease, is not specific to hepatic encephalopathy.