ATI RN
ATI N120n122 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is on anti-retroviral therapy (ART), which includes indinavir sulfate (Crixivan), a protease inhibitor, for the treatment of HIV. Which client statement demonstrates that teaching was effective?
Correct Answer: A
Rationale: This statement accurately reflects the importance of adherence to ART; if medication is missed, the virus may replicate unchecked, leading to drug resistance, which is a significant concern in HIV treatment. The conversion of RNA to DNA is a normal part of the HIV life cycle and is not directly prevented by taking medication on time. While protease inhibitors do help prevent the assembly of new virions, the primary concern when missing doses is the risk of resistance rather than assembly prevention. Missing doses would not directly cause an increase in CD4 lymphocyte counts.
Question 2 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 3 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 4 of 5
Select the appropriate treatment for the following transfusion reactions
| Options | Hemolytic reaction | Anaphylactic reaction |
|---|---|---|
| Administer 0.9% sodium chloride | ||
| Send the blood bag back to the blood bank for analysis. | ||
| Stop blood infusion | ||
| Administer epinephrine |
Correct Answer: A,B,C for Hemolytic; C,D,B,A for Anaphylactic
Rationale: For hemolytic reaction: Administer 0.9% sodium chloride to maintain fluid balance and prevent kidney damage, send the blood bag back for analysis to identify the cause, and stop blood infusion to prevent further hemolysis. For anaphylactic reaction: Stop blood infusion to prevent further exposure to the allergen, administer epinephrine to treat the severe allergic reaction, send the blood bag back for analysis, and administer 0.9% sodium chloride to maintain fluid balance.
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.