ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Check the client's vital signs every 15 min during the transfusion. This is crucial to monitor for any signs of transfusion reaction, such as fever, chills, or hypotension. Vital signs should be closely monitored initially and then at regular intervals to ensure the client's safety. Checking every 15 minutes allows for early detection and prompt intervention if any adverse reactions occur.
Choice B is incorrect because obtaining a blood pressure reading every 30 minutes is not as frequent as checking vital signs every 15 minutes, which is necessary for early detection of adverse reactions.
Choice C is incorrect as starting the transfusion at a rapid rate can lead to adverse reactions like fluid overload or hemolysis. Transfusions should be started at a slow rate to minimize these risks.
Choice D is incorrect because checking vital signs every hour is not frequent enough to detect early signs of transfusion reactions. Regular monitoring every 15 minutes is recommended for safety.
Question 2 of 5
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
Correct Answer: A
Rationale: The correct answer is A: Establish the ability to communicate effectively. For a client who had a left hemispheric CVA, the left hemisphere is responsible for language and speech functions.
Therefore, focusing on establishing effective communication is crucial in the rehabilitation program. It targets the specific deficits caused by the CVA and aims to improve the client's quality of life. Increasing mobility to a normal level (
B) is important but may not be the priority in this case. Promoting independent living without assistance (
C) is a broad goal that may encompass various aspects beyond communication. Restoring full visual function (
D) is not directly related to a left hemispheric CVA.
Question 3 of 5
The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications?
Correct Answer: B
Rationale: The correct answer is B: Carvedilol. Carvedilol is a beta-blocker, which can exacerbate asthma symptoms in clients with a history of asthma due to its potential bronchoconstrictive effects. Furosemide (
A), Spironolactone (
C), and Lisinopril (
D) are commonly used in heart failure management and do not pose a significant risk for clients with asthma. It is crucial to avoid medications that can worsen respiratory function in clients with a history of asthma to prevent complications.
Question 4 of 5
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
Correct Answer: D
Rationale: The correct answer is D: Food should be prepared with purified water. Hepatitis A virus can be spread through contaminated water or food. Using purified water for food preparation can help prevent the transmission of the virus.
Choice A is incorrect because avoiding foods prepared with tap water alone may not be sufficient to prevent hepatitis.
Choice B is incorrect as there is no vaccination available for hepatitis C.
Choice C is important for general hygiene but may not specifically prevent hepatitis transmission.
Question 5 of 5
A nurse is assessing a client who has fluid overload. Which of the following findings shouldn't the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Increased hematocrit. In fluid overload, there is an excess of fluid in the body, leading to dilution of blood components including hematocrit.
Therefore, an increased hematocrit would not be expected. Increased heart rate (
A), blood pressure (
B), and respiratory rate (
C) are all common findings in fluid overload due to the body's compensatory mechanisms to maintain adequate perfusion. Thus, these findings are expected.