ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Provide frequent oral and nares care. This is important because the Sengstaken-Blakemore tube can cause discomfort and irritation to the oral and nasal mucosa, leading to potential complications such as infection or pressure ulcers. Providing frequent oral and nares care helps prevent these complications and ensures the client's comfort.
Choice B is incorrect because monitoring oxygen levels is not directly related to the care of a client with a Sengstaken-Blakemore tube.
Choice C is incorrect because administering intravenous antibiotics is not a routine intervention for a client with a Sengstaken-Blakemore tube unless there is a specific indication for infection.
Choice D is incorrect because the Sengstaken-Blakemore tube should not be removed immediately after 24 hours. The timing of removal should be determined based on the client's condition and the healthcare provider's orders.
Question 2 of 5
A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?
Correct Answer: A
Rationale: The correct answer is A: Poor. In stage IV ovarian cancer, the cancer has spread beyond the ovaries to distant organs, resulting in a poor prognosis. The aggressive treatments may help manage symptoms and prolong survival but the overall prognosis remains poor due to the advanced stage of the cancer.
Choice B (Favorable) is incorrect because stage IV ovarian cancer has a poor prognosis.
Choice C (Uncertain) is incorrect as the prognosis for stage IV ovarian cancer is generally known to be poor.
Choice D (Excellent) is incorrect as stage IV ovarian cancer is not associated with an excellent prognosis due to its advanced stage.
Question 3 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 4 of 5
A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale:
1. Addison's disease is characterized by adrenal insufficiency.
2. Aldosterone is a hormone produced by the adrenal gland that helps regulate blood pressure and electrolyte balance.
3. Lack of aldosterone production in Addison's disease leads to electrolyte imbalances and low blood pressure.
4.
Therefore, the correct answer is A as the lack of aldosterone production by the adrenal gland is the primary cause of Addison's disease.
Summary of other choices:
B. Addison's disease is not caused by a viral infection, so this choice is incorrect.
C. Addison's disease is not caused by the overproduction of cortisol, as it is associated with cortisol deficiency.
D. The most common cause of Addison's disease is an autoimmune disorder where the body attacks the adrenal glands, leading to their dysfunction.
Question 5 of 5
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?
Correct Answer: A
Rationale: The correct answer is A: Pantoprazole 80 mg IV bolus twice daily. In acute pancreatitis, gastric acid hypersecretion can occur, leading to exacerbation of pancreatic inflammation. Pantoprazole is a proton pump inhibitor that helps reduce gastric acid secretion, which can alleviate pancreatic irritation. IV administration ensures rapid onset of action.
B: Furosemide is a diuretic used for conditions like heart failure or edema, not indicated for acute pancreatitis.
C: Lactulose is a laxative used for hepatic encephalopathy to reduce ammonia levels, not indicated for acute pancreatitis.
D: Acetaminophen is a pain reliever, but it does not address the underlying cause of acute pancreatitis.