ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the results of the client's most recent CBC. Fatigue is a common side effect of cisplatin, which can cause bone marrow suppression leading to anemia. Checking the CBC will help determine if the client is experiencing anemia, which can be managed with appropriate interventions. Administering a blood transfusion (
B) should not be done without confirming the need through lab results. Offering a stimulant medication (
C) may mask the underlying cause of fatigue. Advising the client to reduce physical activity (
D) may not address the root cause of the fatigue.
Question 2 of 5
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
Correct Answer: A
Rationale: The correct answer is A: Abnormally prominent U wave. In hypokalemia, low potassium levels can lead to U wave prominence on an EKG. The U wave becomes more visible and prominent due to delayed repolarization of the Purkinje fibers. This is a classic EKG finding in hypokalemia. Tachycardia (choice
B) is a non-specific finding and can be caused by various conditions. Flattened P wave (choice
C) is seen in hyperkalemia, not hypokalemia. Prolonged PR interval (choice
D) is more indicative of first-degree heart block or other conduction abnormalities, not specifically hypokalemia.
Question 3 of 5
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
Correct Answer: D
Rationale: The correct answer is D: Food should be prepared with purified water. Hepatitis A virus can be spread through contaminated water or food. Using purified water for food preparation can help prevent the transmission of the virus.
Choice A is incorrect because avoiding foods prepared with tap water alone may not be sufficient to prevent hepatitis.
Choice B is incorrect as there is no vaccination available for hepatitis C.
Choice C is important for general hygiene but may not specifically prevent hepatitis transmission.
Question 4 of 5
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
Correct Answer: C
Rationale: The correct answer is C: Serosanguineous. This type of drainage is a mixture of clear (serous) and red (sanguineous) fluids, indicating a normal stage of wound healing. The clear fluid suggests minimal inflammation, while the red fluid indicates presence of blood. Serous drainage alone is typically clear and watery without any blood. Sanguineous drainage is bright red and indicates fresh blood. Purulent drainage is thick, opaque, and yellowish-green, suggestive of infection.
Therefore, in this scenario, the observation of watery red drainage best fits the description of serosanguineous drainage.
Question 5 of 5
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct action is to discontinue the existing IV line first. This is crucial because the client is exhibiting signs of infiltration, which can lead to tissue damage and complications. By removing the IV line, further damage can be prevented. Applying warm compresses or elevating the extremity may not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider is important but should not be the first step in this situation.