ATI RN
ATI Nur258 Med Surg 2 Final Exam Questions
Extract:
Question 1 of 5
A nurse is providing discharge planning for a client who has just been diagnosed as being in the early stage of rheumatoid arthritis and starting methotrexate. What should the nurse include in the client's teaching?
Correct Answer: A
Rationale: Monitoring for symptoms of anemia is essential as methotrexate can cause bone marrow suppression, leading to anemia. The nurse should instruct the client to report symptoms like fatigue, pallor, and shortness of breath.
Question 2 of 5
A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?
Correct Answer: A
Rationale: Current anticoagulant use is crucial to assess before administering t-PA because combining t-PA with anticoagulants can significantly increase the risk of bleeding complications. It is essential to ensure that the client is not on medications that could interact adversely with t-PA.
Question 3 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 4 of 5
A nurse is assessing a client with chronic liver failure who tells the nurse he is experiencing spontaneous episodes of bleeding and has noted increased areas of bruising on his arms. The nurse suspects the client has a deficiency in which of the following vitamins?
Correct Answer: C
Rationale: Vitamin K is essential for the synthesis of clotting factors produced by the liver. In chronic liver failure, the liver's ability to produce these factors is impaired, leading to an increased risk of bleeding and bruising due to vitamin K deficiency.
Question 5 of 5
A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: In a disaster situation, prioritizing care for clients with life-threatening emergencies is crucial to ensure that those in the most critical condition receive immediate attention. This aligns with triage principles and ensures that limited resources are used effectively.