ATI RN
ATI Medical Surgical 2 Final 2024 Assessment Questions
Extract:
Question 1 of 5
A nurse is caring for a female client who has rheumatoid arthritis and a new prescription for methotrexate. The client tells the nurse she is planning a pregnancy. Which of the following instructions should the nurse give the client?
Correct Answer: D
Rationale: Methotrexate should be discontinued at least 3 months prior to a planned pregnancy to ensure it is cleared from the body, as it can cause serious birth defects. Reducing the dosage is not safe, as methotrexate is contraindicated in pregnancy. Dietary modifications are not the primary concern, and breastfeeding is not recommended due to potential harm to the infant.
Question 2 of 5
A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?
Correct Answer: D
Rationale: Airway patency is the priority post-thyroidectomy due to the risk of swelling or hematoma causing obstruction. Temperature, urination, and pain control are important but secondary.
Question 3 of 5
A nurse is caring for an older adult client who had a femoral head fracture 24 hours ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
Correct Answer: D
Rationale: Fat embolism syndrome is a serious condition that occurs when fat globules enter the bloodstream and lodge within the pulmonary vasculature, leading to respiratory distress. It is a known complication following long bone fractures, such as the femur, and presents with symptoms like shortness of breath, hypoxemia, and neurological manifestations. Given the recent femoral head fracture and the symptoms reported, fat embolism syndrome is the most likely diagnosis.
Question 4 of 5
A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority?
Correct Answer: A
Rationale: When a nurse administers an incorrect insulin dose, the immediate concern is the risk of hypoglycemia, especially since the insulin dose given was for a higher blood glucose level than the actual reading. Hypoglycemia can occur when blood glucose levels drop below 70 mg/dL. Symptoms of hypoglycemia include shakiness, sweating, confusion, and in severe cases, loss of consciousness. Monitoring the client for hypoglycemia allows the nurse to detect and treat it promptly, ensuring the client's safety. While completing an incident report is important for documenting the medication error and preventing future occurrences, it is not the immediate priority. The nurse's first responsibility is to ensure the client's safety by addressing the potential hypoglycemia. Once the client's condition is stable, the nurse can then complete the incident report. Administering 15 to 20 grams of carbohydrate is a treatment for hypoglycemia. However, this action should only be taken if the client is actually experiencing hypoglycemia. The nurse should first monitor the client's blood glucose levels to confirm hypoglycemia before administering carbohydrates. Notifying the nurse manager is important for accountability and to ensure that appropriate follow-up actions are taken. However, it is not the immediate priority. The nurse should first monitor the client for hypoglycemia and address any immediate health concerns before notifying the nurse manager.
Question 5 of 5
A nurse is formulating a teaching plan about herpes zoster for a group of older adults at a community center. The nurse should include which of the following information in the plan?
Correct Answer: A,B,C
Rationale:
Choice A: Herpes zoster lesions are indeed contagious if they are draining. The virus can spread through direct contact with the fluid from the blisters. It is crucial to cover the lesions to prevent spreading the virus to others, especially to those who have never had chickenpox or the vaccine.
Choice B: The development of vesicles, which are small fluid-filled blisters, is a hallmark of herpes zoster. These vesicles typically appear in a band-like pattern on one side of the body and are often accompanied by pain, itching, or tingling before they are visible.
Choice C: Postherpetic neuralgia is a condition where the pain persists in the area of the herpes zoster rash even after the lesions have healed. This can last for weeks, months, or even years and is more common in older adults.
Choice D: Herpes zoster itself is not spread like chickenpox. It occurs when the varicella-zoster virus, which has been lying dormant in the nerve cells, reactivates. While it is possible for someone who has never had chickenpox to develop chickenpox after direct contact with a shingles rash, herpes zoster is not 'easily spread' to others in the same way that chickenpox is.