ATI RN
ATI N120n122 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has human immunodeficiency virus (HIV). Which laboratory value should the nurse alert the provider of?
Correct Answer: B
Rationale: A CD4-T-cell count of 180 cells/mm³ is significantly low (normal range: 500 to 1500 cells/mm³) and indicates severe immunosuppression, putting the client at increased risk for opportunistic infections, warranting immediate attention from the provider. A positive Western blot test indicates an HIV diagnosis, which is expected in a client with HIV and does not require urgent intervention. A platelet count of 150,000/mm³ is at the lower end of the normal range and does not typically require immediate intervention unless there are clinical symptoms associated. A WBC count of 5,000/mm³ is within the normal range and does not indicate a need for urgent intervention.
Question 2 of 5
A nurse is administering a unit of RBC 350 mL over 3 hr to a client who has anemia. 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: 117
Rationale: Infusion rate (mL/hr) = Volume to be infused (mL) / Time (hr). In this case: Volume to be infused = 350 mL, Time = 3 hours. Plugging the values into the formula: Infusion rate = 350 mL / 3 hours = 116.67 mL/hr. Rounding to the nearest whole number, the infusion rate is 117 mL/hr.
Question 3 of 5
A nurse is providing teaching to a client who has vitamin B12 deficiency. Which of the following foods should the nurse instruct the client to consume? Select all that apply.
Correct Answer: B,E,F
Rationale: Eggs, beef, and milk are good sources of vitamin B12 and should be included in the diet of someone with a deficiency. Bananas, spinach, carrots, and quinoa are not significant sources of vitamin B12.
Question 4 of 5
The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select three options that apply.
Correct Answer: A,E,F
Rationale: Ensuring comfortable seating at eye level establishes a non-intimidating environment. Setting the room temperature at a comfortable level ensures physical comfort. Removing distracting objects minimizes potential distractions. Facing a strong light may cause discomfort. A distance of 7 ft is too great for effective communication. Placing a chair across from the nurse's desk creates a formal, potentially intimidating setting.
Question 5 of 5
A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Correct Answer: B
Rationale: Generalized urticaria, or hives, is a classic sign of an allergic transfusion reaction, presenting as an itchy rash or welts on the skin. Distended jugular veins may indicate fluid overload or congestive heart failure, not an allergic reaction. Bilateral flank pain is more indicative of a hemolytic reaction, particularly due to kidney involvement, rather than an allergic reaction. A blood pressure of 184/92 mm Hg may suggest hypertension or a reaction, but it is not specific to allergic transfusion reactions, which are characterized by skin symptoms like urticaria.