ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: The correct answer is A: Bleeding from the gums. Myelosuppression leads to decreased production of blood cells, including platelets, which are essential for clotting. Bleeding from the gums is a common sign of thrombocytopenia, a condition where there are low platelet levels. Chest pain, fatigue, and severe headache are not directly associated with myelosuppression. Monitoring for bleeding tendencies is crucial in clients with myelosuppression to prevent complications like hemorrhage.
Question 2 of 5
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
Correct Answer: A
Rationale: The correct answer is A. The rise in the water seal chamber with client inspiration indicates that the chest tube system is functioning properly. This rise is expected as the negative pressure in the pleural space increases during inspiration, causing the water level to momentarily increase. It is important for the nurse to understand this physiological response and continue to monitor the client for any signs of respiratory distress. Notifying the healthcare provider immediately or increasing suction level is unnecessary and may disrupt the client's respiratory status. Repositioning the client is not indicated in this situation.
Question 3 of 5
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Establish a plan of care with the client that sets attainable goals. This is because involving the client in setting realistic goals can empower them and increase motivation for rehabilitation. By collaborating with the client, the nurse can address the client's needs and preferences, leading to a more personalized and effective rehabilitation plan. Encouraging the client to actively participate in their care promotes autonomy and fosters a sense of control over their situation.
Other choices are incorrect:
A: Encouraging the client to discuss their feelings is important, but it may not directly address the need for a structured plan of care with attainable goals.
C: Increasing the frequency of physical therapy sessions may be overwhelming for the client and not address the underlying issue of lack of motivation.
D: Allowing the client to set the schedule for rehabilitation may not provide the structure and guidance needed for effective rehabilitation.
Question 4 of 5
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?
Correct Answer: A
Rationale:
Correct Answer: A. Do not apply heat to the area of irradiation.
Rationale: Heat can increase skin sensitivity and damage during radiation therapy. It is important to avoid any source of heat on the irradiated area to prevent further skin irritation and burns.
Summary:
B. Using sunscreen is not necessary for radiation therapy as it does not protect against radiation.
C. Applying lotion generously can interfere with the radiation treatment and cause skin irritation.
D. Rubbing the area with an alcohol-based lotion can further irritate the skin and is not recommended during radiation therapy.
Question 5 of 5
A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?
Correct Answer: B
Rationale: The correct answer is B: Erythrocyte sedimentation rate (ESR). ESR is a common test used to monitor inflammation levels in rheumatoid arthritis (R
A) patients. Aspirin is an anti-inflammatory medication, so monitoring ESR can help assess the effectiveness of the treatment. A decrease in ESR levels indicates a reduction in inflammation, suggesting that the aspirin is working. The other choices (A, C,
D) are not specific to monitoring the effectiveness of aspirin in RA. C-reactive protein and white blood cell count are general markers of inflammation and infection, not specific to RA. Hematocrit measures red blood cell levels, which are not directly related to the effectiveness of aspirin in treating RA.