ATI RN
ATI N120n122 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is receiving a unit of packed red blood cells. Which client statement suggests manifestation of an acute hemolytic reaction?
Correct Answer: A
Rationale: Sharp pain in the lower back is a classic symptom of an acute hemolytic reaction, which can occur due to incompatible blood transfusions. Coughing more could indicate a transfusion-related acute lung injury (TRALI) but is not a typical sign of an acute hemolytic reaction. Ringing in the ears can occur with other conditions but is not a common sign of an acute hemolytic reaction. Feeling needles poking in the feet is vague and not specifically associated with acute hemolytic reactions.
Question 2 of 5
A client with iron deficiency anemia is prescribed ferrous sulfate. Which instruction by the nurse is most appropriate to include in the client's teaching plan?
Correct Answer: C
Rationale: Stools becoming darker in color is a common and expected side effect of ferrous sulfate due to the presence of unabsorbed iron. It is important for clients to know this to avoid unnecessary alarm. Decreasing intake of foods high in fiber is not necessary; in fact, fiber can help prevent constipation, a common side effect of iron supplements. Vitamin C enhances the absorption of iron; thus, avoiding it is incorrect. Taking the medication on a full stomach may decrease absorption.
Question 3 of 5
A nurse is caring for a client with HIV. Which laboratory test would be used to assess the effectiveness of therapy?
Correct Answer: A
Rationale: Viral load count is the primary test used to assess the effectiveness of HIV therapy by measuring the amount of HIV RNA in the blood, indicating how well the treatment is controlling the virus. The Western blot is used as a confirmatory test for HIV diagnosis rather than monitoring therapy effectiveness. The Enzyme immunoassay (EI
A) test is used for initial HIV screening but does not measure viral load or therapy effectiveness. Platelet count can be affected in HIV infection, especially with advanced disease, but it does not directly measure the effectiveness of HIV therapy.
Question 4 of 5
The client with sickle cell disease (SCD) has recently been sick and is now experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement?
Correct Answer: D
Rationale: Maintaining IV fluids, administering pain medications, and providing supplemental oxygen are critical interventions that address the acute needs of the client in crisis, aiming to alleviate pain and improve oxygenation. Encouraging frequent ambulation is not appropriate during a vaso-occlusive crisis, as it can exacerbate pain and further compromise blood flow. While monitoring the RBC count is important, it is not the most immediate intervention during a crisis. Treating the client in an outpatient setting is inappropriate during a vaso-occlusive crisis, which typically requires inpatient care for effective pain management and hydration.
Question 5 of 5
A nurse is teaching a client with a history of ulcerative colitis and a new diagnosis of anemia. Which of the following symptoms from ulcerative colitis is a contributing factor to the development of anemia?
Correct Answer: C
Rationale: Chronic bloody diarrhea is a significant symptom of ulcerative colitis and leads to iron loss and depletion, contributing to the development of anemia due to the loss of blood and iron. Dietary iron restrictions may affect iron intake, but they are not a direct symptom of ulcerative colitis that contributes to anemia. Intestinal parasites can cause anemia but are not a common complication associated with ulcerative colitis. Intestinal malabsorption syndrome can lead to anemia; however, it is not a primary symptom of ulcerative colitis itself.