ATI RN
ATI Med Surg Exam 9 Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Changing the IV tubing every 24 hours is recommended to prevent infection and maintain sterility, as TPN can support bacterial growth (
Choice
C). Blood glucose should be monitored every 4-6 hours, not every 12 hours, due to TPN's high-glucose content affecting blood sugar levels (
Choice
A). IV site dressings should be changed daily or as needed to prevent infection, not every 4 days (
Choice
B). The client should be weighed daily, not every other day, to assess fluid balance and nutritional status (
Choice
D).
Question 2 of 5
A client admitted with an acute exacerbation of Ménière's disease asks the student nurse why he was prescribed diphenhydramine. Which response by the student nurse requires correction by the primary nurse?
Correct Answer: A
Rationale: Ménière's disease is not caused by an allergic response; its cause is unknown but may involve fluid imbalance or infection. Diphenhydramine, an antihistamine with anticholinergic properties, correctly helps reduce nausea, vomiting, and promotes rest.
Question 3 of 5
A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?
Correct Answer: B
Rationale: A change in the Glasgow Coma Scale score from 14 to 10 indicates a deterioration in neurological status, potentially due to increased intracranial pressure, requiring immediate reporting to the provider.
Question 4 of 5
A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?
Correct Answer: D
Rationale: The NG tube decompresses the stomach and removes secretions, alleviating distension and preventing complications in acute peritonitis.
Question 5 of 5
A client arrives to the clinic with reports of progressive weakness in his lower extremities. Which of the following findings in the client's history is consistent with the client developing Guillain-Barre syndrome?
Correct Answer: D
Rationale: Reason: A facial tumor is not related to Guillain-Barre syndrome, which is an autoimmune disorder that affects the peripheral nerves. Reason: Pregnancy is not a risk factor for Guillain-Barre syndrome, although it can occur during or after pregnancy in rare cases. Reason: A puncture wound 3 weeks ago is unlikely to cause Guillain-Barre syndrome, which usually follows a respiratory or gastrointestinal infection. Reason: This is the correct answer because cytomegalovirus is one of the common infections that can trigger Guillain-Barre syndrome. It can cause inflammation and damage to the myelin sheath that covers the nerves.