ATI RN
ATI N120n122 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). The nurse notes white lesions on the client's tongue. What opportunistic infection is this client experiencing?
Correct Answer: A
Rationale: Candidiasis, commonly known as thrush, is characterized by white lesions on the tongue and is a common opportunistic infection in clients with AIDS due to their compromised immune system. Xerostomia refers to dry mouth and does not cause white lesions; it can occur in various conditions but is not an opportunistic infection. Halitosis is bad breath and does not correlate with white lesions on the tongue; it can result from various causes but is not an infection. Gingivitis involves inflammation of the gums and may present with red, swollen gums but does not typically cause white lesions on the tongue.
Question 2 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 3 of 5
A client with iron deficiency anemia is prescribed ferrous sulfate. Which instruction by the nurse is most appropriate to include in the client's teaching plan?
Correct Answer: C
Rationale: Stools becoming darker in color is a common and expected side effect of ferrous sulfate due to the presence of unabsorbed iron. It is important for clients to know this to avoid unnecessary alarm. Decreasing intake of foods high in fiber is not necessary; in fact, fiber can help prevent constipation, a common side effect of iron supplements. Vitamin C enhances the absorption of iron; thus, avoiding it is incorrect. Taking the medication on a full stomach may decrease absorption.
Question 4 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.
Question 5 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.