ATI RN
ATI Med Surg Pharm Comprehensive Exam 1 Questions
Extract:
Question 1 of 5
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
Correct Answer: B
Rationale: Temperature is important to monitor for baseline and the temperature should be monitored during infusion since an increase in temperature can indicate a transfusion reaction.
Question 2 of 5
A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?
Correct Answer: D
Rationale: Placing partial weight on the affected leg while ambulating with crutches using a three-point gait is incorrect and can jeopardize safety by potentially causing injury or instability.
Extract:
Nurses' Notes
0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk."
0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily.
0915: Fecal mass of hard, dry stool removed digitally from client per provider's order.
1015: Provided teaching to client and partner about constipation and methods to avoid further impaction.
Diagnostic Results
0900:
Abdominal x-ray: Large amount of fecal material throughout the colon with rectal impaction. No evidence of small bowel obstruction.
Question 3 of 5
A nurse is providing teaching to a client who has constipation. Which of the following information should the nurse include?(Select all that apply.)
Correct Answer: C,D,E
Rationale: Including probiotic foods in the diet can help maintain a healthy gut flora, which is beneficial for digestion and preventing constipation. It is crucial to increase fluid intake, aiming for at least 1500 mL daily, to help soften the stool and support regular bowel movements. Increasing daily exercise, especially walking, can stimulate the muscles involved in the digestive process and help prevent constipation.
Extract:
Question 4 of 5
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)
Correct Answer: A
Rationale:
To calculate the infusion rate for an IV, the total volume to be infused (in this case, 1000 mL) is divided by the total time of infusion (8 hours). So, the calculation would be 1000 mL divided by 8 hours, which equals 125 mL per hour.
Extract:
Nurses Notes
Hospital Day 1
1700:
Client admitted to the medical surgical unit for reports of right leg swelling and pain. Area of redness and swelling noted to right thigh with small white pustule in center. Area is warm and tender to touch. Area marked with an indelible marker. Morphine and first dose of cefuroxime administered in the emergency department. Client resting comfortably.
0800:
Client alert and oriented to person, place, and time. Reports right leg pain interrupted sleeping: rates pain as 8on 0 to 10 scale. Lungs clear bilaterally, respirations unlabored. Heart rhythm regular. Abdomen soft and non-distended, bowel sounds present all 4 quadrants.
Vital Signs
0800:
Temperature 37.1 °C (98.8 °F)
Heart rate 48/min
Respiratory rate 14/min
Blood pressure 122/84 mm Hg
0815:
Heart rate 42/min
Respiratory rate 10/min
Blood pressure 108/62 mm Hg
Medication Administration Record
Provider Prescriptions
Admission: Cefuroxime 250 mg po q12h (0800, 1600)
Lovastatin 20 mg po qd with dinner (1800)
Pantoprazole 40 mg po qd (0800)
Morphine 30 mg po q4h prn for pain
Propranolol 40 mg po bid, hold for apical pulse < 50/min (0800, 1600)
Question 5 of 5
The nurse reviews the medication administration record following the 0815 assessment findings. Which of the following administered medications would require an incident report?
Correct Answer: A
Rationale: Propranolol is a beta-blocker used to control blood pressure and heart rate. However, the nurse has a hold order for propranolol if the apical pulse (heart rate) is less than 50 beats per minute. The nurse documented a heart rate of 42 bpm at 0815, which falls below the hold parameter for propranolol. Administering propranolol in this case could worsen the client's bradycardia (slow heart rate) and therefore requires an incident report.