ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Correct Answer: C
Rationale: The correct answer is C: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. It is caused by histamine release in response to the foreign blood product. Chest pain (
A) is more indicative of a possible cardiac issue. Hypotension (
B) may suggest a hemolytic reaction due to rapid destruction of red blood cells. Fever (
D) is a common symptom of a febrile non-hemolytic transfusion reaction. Other choices are incorrect as they are not specific to an allergic reaction.
Question 2 of 5
A nurse works with an AP assigned to bathe a client with herpes zoster. The AP asks if it is contagious. What should the nurse say?
Correct Answer: A
Rationale: The correct answer is A. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. Individuals who have had chickenpox in the past are not at risk of getting shingles from someone with herpes zoster. The virus is not transmitted through the air (choice
B) or through blood contact only (choice
D). It is not highly contagious to everyone (choice
C). By explaining to the AP that herpes zoster is not contagious to individuals who have had chickenpox, the nurse provides accurate information and helps alleviate concerns about the spread of the virus.
Question 3 of 5
A nurse teaches a client with breast cancer about chemotherapy side effects. What statement indicates understanding?
Correct Answer: A
Rationale: The correct answer is A because it shows the client understands the importance of monitoring for potential side effects like unusual menstrual bleeding, which can be a serious complication of chemotherapy. This statement reflects proactive involvement in self-care and prompt communication with healthcare providers.
Choices B, C, and D are incorrect because stopping chemotherapy without medical guidance can be harmful, hair loss may not always be permanent, and follow-up tests are essential for monitoring treatment effectiveness and potential complications.
Question 4 of 5
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
Correct Answer: A
Rationale: The correct answer is A: Perform a 12-lead ECG. This is because an ECG is the most reliable and direct way to assess for myocardial infarction by identifying characteristic changes in the heart's electrical activity. Nitroglycerin (
B) is used to relieve chest pain but should not be administered before confirming the diagnosis. Placing the client in a prone position (
C) is not appropriate for assessing chest pain. Assessing blood pressure (
D) is important but not the initial priority when suspecting myocardial infarction.
Question 5 of 5
A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: The urethral orifice is located between the clitoris and vaginal opening, so separating the labia minora is necessary to assess it. This step ensures proper assessment of the urinary system and helps detect any abnormalities.
Summary of Incorrect
Choices:
B: Palpating the cervix for size is not a standard part of a gynecological examination; it may cause discomfort and is unnecessary unless indicated for specific medical reasons.
C: Inspecting the vagina without a speculum is not recommended as it may not provide a clear view of the vaginal walls and cervix, potentially missing important findings.
D: Massaging the clitoris is not a part of a gynecological examination and is inappropriate; it may be uncomfortable for the patient and is not relevant to the assessment.