ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
Correct Answer: B
Rationale: The correct answer is B: Paresthesia. Pernicious anemia is caused by a lack of vitamin B12, leading to nerve damage. Paresthesia, or tingling and numbness in the extremities, is a common symptom. This poses a risk to the client's safety as it may result in decreased sensation and coordination, increasing the risk of falls and injuries. Loss of hearing (
A), muscle wasting (
C), and changes in vision (
D) are not directly associated with pernicious anemia and do not pose an immediate safety risk in this context.
Question 2 of 5
A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement?
Correct Answer: D
Rationale: The correct answer is D: Ensure lights are dimmed in the client's room. Dimming the lights can help decrease stimulation and minimize discomfort for a client with bacterial meningitis, as they may be sensitive to light due to photophobia, which is a common symptom in meningitis. It can also help reduce the risk of exacerbating headaches and other symptoms.
Incorrect choices:
A: Initiating airborne precautions is not necessary for bacterial meningitis, as it is not transmitted through the air.
B: Ensuring the client's bed is positioned to greater than 45° is not directly related to the care of a client with bacterial meningitis.
C: Encouraging frequent ambulation may not be appropriate for a client with bacterial meningitis, as they may be too weak or ill to ambulate.
E, F, G: There are no additional choices provided, but they would likely be incorrect as they are not relevant to the care of a client with bacterial meningitis.
Question 3 of 5
A nurse is planning care for a client who has *Clostridium difficile* gastroenteritis. Which of the following is an appropriate nursing action?
Correct Answer: C
Rationale: The correct answer is C: Obtain a stool specimen with gloves.
Rationale:
1. Clostridium difficile is transmitted through contact with feces, so obtaining a stool specimen with gloves is essential to prevent the spread of infection.
2. Using gloves during specimen collection reduces the risk of contaminating hands and surfaces.
3. It is important to identify the specific pathogen causing the gastroenteritis to determine the appropriate treatment.
Summary of incorrect choices:
A: Placing the client in a protective environment is not necessary for Clostridium difficile gastroenteritis.
B: Cleaning surfaces with chlorhexidine is important for infection control but not the most appropriate action in this scenario.
D: Washing hands with alcohol-based hand rub is important for general infection control but not specific to obtaining a stool specimen.
Overall, choice C is the most relevant and appropriate nursing action in this situation.
Question 4 of 5
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag, which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Use 0.9% sodium chloride to perform an intermittent bladder irrigation. In this scenario, the client is experiencing bladder spasms and a scant amount of fluid in the drainage bag, indicating a potential blockage or clot in the catheter. Performing an intermittent bladder irrigation with 0.9% sodium chloride can help to clear the catheter and improve urine flow. This intervention helps prevent further complications such as urinary retention or infection. Encouraging the client to unseat or applying a cold compress may not address the underlying issue of catheter blockage. Securing the catheter to the upper left quadrant does not directly address the current problem and may not improve urine flow.
Question 5 of 5
A nurse is caring for a client who is postoperative following a below-the-knee amputation. Which of the following statements made by the client indicates acceptance of their altered body image?
Correct Answer: A
Rationale: The correct answer is A because the statement indicates the client's willingness to connect with someone who has undergone a similar experience, showing acceptance and readiness to learn from others in similar situations. This demonstrates the client's acknowledgment of their altered body image and a proactive approach towards coping with it positively.
Choice B reflects avoidance behavior, not acceptance.
Choice C focuses on the relief of pain rather than acceptance of body image changes.
Choice D suggests resignation rather than acceptance.