ATI RN
ATI RN Adult Medical Surgical 2023 Questions Questions
Extract:
Question 1 of 5
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Place a large face clock in the client's bedroom. This is important for clients with Alzheimer's disease as it helps them maintain a sense of time and routine. People with Alzheimer's often struggle with time perception, so having a clock with large, easy-to-read numbers can assist them in understanding the time of day. This can help reduce confusion and anxiety.
A: Keeping the client's bedroom dark at night may increase confusion and disorientation for someone with Alzheimer's.
B: Covering electrical outlets with tape is not relevant to caring for a client with Alzheimer's at home.
C: Hanging a monthly calendar in the client's bedroom may not be as effective as a large face clock in helping the client understand time.
Question 2 of 5
A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interact with this medication?
Correct Answer: B
Rationale: The correct answer is B: Kale. Kale is high in vitamin K, which can interfere with the anticoagulant effects of warfarin by increasing the clotting factors in the blood, leading to a decreased INR. It is important for patients on warfarin to maintain a consistent intake of vitamin K-rich foods to ensure their INR remains within the therapeutic range. Orange juice (
A), beef stew (
C), and yogurt (
D) do not significantly interact with warfarin. A summary of why they are incorrect: Orange juice does not have a direct interaction with warfarin. Beef stew does not contain significant amounts of vitamin K. Yogurt is not a high vitamin K food.
Question 3 of 5
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
Correct Answer: B
Rationale: The correct answer is B: Paresthesia. Pernicious anemia is caused by a lack of vitamin B12, leading to nerve damage. Paresthesia, or tingling and numbness in the extremities, is a common symptom. This poses a risk to the client's safety as it may result in decreased sensation and coordination, increasing the risk of falls and injuries. Loss of hearing (
A), muscle wasting (
C), and changes in vision (
D) are not directly associated with pernicious anemia and do not pose an immediate safety risk in this context.
Question 4 of 5
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice
A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice
C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice
D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
Question 5 of 5
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client is showing signs of a transfusion reaction, which can be serious. Stopping the infusion is the first priority to prevent further complications. Vital signs should be checked next to assess the client's condition. Collecting a urine sample is not a priority in this situation. Administering oxygen may be necessary depending on the client's condition, but stopping the infusion takes precedence.