ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who has leukemia and a platelet count of 60,000/mm³ (nl. 140,000-400,000/mm³). Which intervention should the nurse include in the plan of care?
Correct Answer: B
Rationale: Administering stool softeners is a key intervention for clients with thrombocytopenia, as it helps to prevent straining during bowel movements, which could cause rectal bleeding due to fragile blood vessels.
Question 2 of 5
A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
Correct Answer: D
Rationale: Reminding the client that he might feel a constant urge to void is essential. Continuous bladder irrigation can cause bladder spasms and a persistent sensation of needing to urinate, which is common after TURP. This helps the client understand and cope with these sensations, reducing anxiety and unnecessary concern.
Question 3 of 5
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?
Correct Answer: C
Rationale: Reducing protein intake is crucial for decreasing ammonia production. In clients with hepatic encephalopathy, proteins are broken down into ammonia, which the impaired liver cannot detoxify effectively, leading to worsened symptoms.
Therefore, reducing dietary protein can help lower ammonia levels.
Question 4 of 5
A nurse is caring for a client who has human immunodeficiency virus (HIV). Which of the following laboratory values would be most concerning to the nurse?
Correct Answer: D
Rationale: A WBC count of 800/mm³ is severely low and indicates a high risk for infection, which is particularly concerning in a client with HIV, as it suggests significant immunosuppression and vulnerability to opportunistic infections.
Question 5 of 5
The emergency department (ED) staff has been notified of the imminent arrival of a client who has experienced respiratory exposure to the chemical agent chlorine. Which finding should the anticipate with this exposure?
Correct Answer: D
Rationale: Pulmonary edema is a common and severe consequence of chlorine gas inhalation due to the corrosive effect of chlorine on the respiratory tract, leading to fluid accumulation in the lungs.