ATI RN
RN ATI Adult Medsurg Proctored Exam 2023 With NGN Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is receiving vancomycin intermittent IV bolus therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the medication?
Correct Answer: B
Rationale: The correct answer is B: The client is becoming flushed. Flushing is a common adverse effect of vancomycin, indicating a possible allergic reaction or infusion reaction. Flushing can be a sign of red man syndrome, a severe reaction to vancomycin. The nurse should monitor closely and report this finding to the healthcare provider.
Incorrect Answer
Rationale:
A: The client reports ringing in the ears - this is a potential adverse effect of vancomycin, but not as critical as flushing.
C: The client reports increased thirst - this is not typically associated with vancomycin adverse effects.
D: The client has a decreased urine output - this may indicate nephrotoxicity, a known side effect of vancomycin, but flushing is more indicative of an immediate adverse reaction.
Question 2 of 5
A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the clients plan of care?
Correct Answer: A
Rationale: The correct answer is A: Assess the PICC infusion system systematically. This is essential to monitor for signs of infection, occlusion, or dislodgement of the catheter. Regular assessment can help identify any issues early and prevent complications.
Summary:
B: Flushing the line only before infusing medication is incorrect as regular flushing is necessary to maintain catheter patency.
C: Using a sterile dressing every 7 days is incorrect as the dressing should be changed according to facility protocol or if it becomes soiled or loose.
D: Allowing the catheter to remain uncapped when not in use is incorrect as it can increase the risk of contamination and infection.
Question 3 of 5
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
Correct Answer: A, C
Rationale: The correct answers are A and C. Neutropenia and chemotherapy increase the risk of infection. Avoiding crowds (
A) reduces exposure to infectious agents. Taking temperature daily (
C) helps detect early signs of infection. Washing toothbrush weekly (
B) is important but daily is recommended. Eating fresh fruits and vegetables (
D) is beneficial but may pose infection risk.
Question 4 of 5
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. This is crucial post total hip arthroplasty to prevent dislocation. Abduction helps keep the hip joint stable and reduces the risk of the prosthesis slipping out of place.
Choices B, C, and D are incorrect. High Fowler's position (
B) is not necessary for this specific postoperative care. Crossing legs at the ankles (
C) can lead to hip dislocation. Having the client bend forward at the waist (
D) can also increase the risk of dislocation.
Question 5 of 5
A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: The correct answer is B: Place monitoring cords and tubes in a stockinette. This is important for the client with a latex allergy because stockinettes provide a barrier between the latex-containing materials and the client's skin, reducing the risk of allergic reactions. Using powder-free latex gloves (choice
A) is a good practice, but it is not directly addressing the risk of exposure to latex for the client. Avoiding iodine-based antiseptics (choice
C) is not necessary unless the client has a specific allergy to iodine. Administering prophylactic antihistamines (choice
D) is not a standard practice for latex allergies and may not prevent an allergic reaction.