ATI RN
ATI Medsurg Proctored Final Exam Questions
Extract:
Question 1 of 5
A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?
Correct Answer: A
Rationale: The correct answer is A: "I may eat 10 ounces of lean protein each day." This statement indicates a need for further teaching because consuming 10 ounces of lean protein daily may lead to excessive protein intake, which can strain the kidneys and potentially worsen hypertension. Clients with hypertension should limit protein intake and focus on lean sources in moderation.
Choices B, C, and D are correct as they align with a heart-healthy diet by limiting sodium intake, increasing fruits and vegetables, and avoiding fried foods and processed meats, respectively.
Question 2 of 5
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: The correct answer is A: Bleeding from the gums. Myelosuppression leads to decreased production of blood cells, including platelets, which are essential for clotting. Bleeding from the gums is a common sign of thrombocytopenia, a condition where there are low platelet levels. Chest pain, fatigue, and severe headache are not directly associated with myelosuppression. Monitoring for bleeding tendencies is crucial in clients with myelosuppression to prevent complications like hemorrhage.
Question 3 of 5
A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor?
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. This can lead to hypokalemia, which can be dangerous in a client with heart failure as it can worsen cardiac function and lead to arrhythmias. The nurse should monitor the client's potassium levels regularly to prevent this adverse effect.
Summary of other choices:
B: Hyperkalemia - Furosemide does not typically cause hyperkalemia.
C: Hypernatremia - Furosemide is a diuretic that can lead to sodium loss, not hypernatremia.
D: Hypertension - Furosemide is actually used to treat hypertension, so it is not an adverse effect of the medication in this scenario.
Question 4 of 5
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Preoxygenate the client with 100% oxygen for up to 3 min. This is essential to prevent hypoxemia during the suctioning procedure. Adequate preoxygenation helps to increase the oxygen reserves in the client's lungs, reducing the risk of oxygen desaturation during and after suctioning. This is particularly important for clients with COPD and an artificial airway, as they are already at risk for hypoxemia due to impaired lung function.
Choices B, C, and D are incorrect:
B: Performing suctioning for no longer than 30 seconds is a general guideline, but it is not specific to clients with COPD and an artificial airway.
C: Applying suction while inserting the catheter is incorrect as this can cause trauma to the airway and increase the risk of infection.
D: Limiting oxygen therapy to 50% prior to suctioning is incorrect as it can lead to hypoxemia in clients with
Question 5 of 5
A nurse is caring for a client receiving TPN. What action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Check the client's capillary blood glucose level every 4 hr. This is crucial because TPN can cause hyperglycemia due to its high glucose content. Monitoring blood glucose levels helps in detecting and managing hyperglycemia.
Incorrect answers:
A: Monitoring serum sodium levels is not directly related to TPN administration.
C: Administering the solution at room temperature is not necessary for TPN administration.
D: Discontinuing TPN abruptly can lead to serious complications; it should be gradually tapered off.
Overall, monitoring blood glucose levels is essential in TPN therapy to prevent complications related to hyperglycemia.