ATI RN
ATI Med Surg Pharm Comprehensive Exam 1 Questions
Extract:
Question 1 of 5
A nurse using the principle-based approach to client care seeks to avoid causing harm to clients in all situations. What is this principle known as?
Correct Answer: C
Rationale: Nonmaleficence is a core principle in healthcare ethics and emphasizes the primary duty of healthcare providers to do no harm to their clients.
Question 2 of 5
A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?
Correct Answer: A
Rationale: Checking the patency of the client's airway is the priority action because maintaining a clear airway is crucial during a seizure to ensure adequate oxygenation and prevent aspiration.
Question 3 of 5
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
Correct Answer: C
Rationale: CD4-T-cell count is crucial for monitoring HIV progression and immune function. A low count indicates immunosuppression and increased risk of opportunistic infections.
Question 4 of 5
A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following information should the nurse provide?
Correct Answer: B
Rationale: Drinking 2 to 3 L of water per day helps prevent kidney damage and reduces the risk of side effects such as methotrexate toxicity.
Extract:
History and Physical
Diabetes mellitus type 2 for 15 years
Hypertension for 25 years
Hyperlipidemia for 20 years
History of smoking 40 packs per year
Cerebrovascular accident (CVA) 5 days ago
Nurses' Notes
Day 1, Medical-Surgical Unit (5 days post-CVA):
Client transferred from ICU via gurney, hand-off report received. Client asleep, respirations eupneic, heart rate regular. Abdomen soft, nondistended, active bowel sounds x4 quadrants. No edema noted, compression stockings present. Indwelling urinary catheter draining clear yellow urine. 14 French NG tube noted in right nares, clamped.
Day 2, Medical-Surgical Unit (6 days post-CVA):
Assessment completed. Client awakens for short periods of time, unable to speak, occasional moans noted. Client incontinent of stool, cleaned skin and barrier ointment applied. Skin intact without any areas of erythema. Client unable to reposition self. Occasional movement of left arm and leg noted, right side without movement. Physical therapists in to see client for morning exercises. NG tube noted in right nares, clamped.
Provider Prescriptions
Day 1, Medical-Surgical Unit (5 days post-CVA):
Begin clopidogrel 75 mg via NG tube daily
Diagnostic Results
Day 1, Medical-Surgical Unit (5 days post-CVA):
WBC count 6,900/mm3 (5,000 to 10,000/mm3)
Hgb 16 g/dL (12 g/dL to 16 g/dL)
Hct 41% (37% to 47%)
Platelet count 310,000/mm3 (150,000 to 400,000/mm3)
Day 2, Medical-Surgical Unit (6 days post-CVA):
WBC count 7,200/mm3 (5,000 to 10,000/mm3)
Hgb 16.5 g/dL (12 g/dL to 16 g/dL)
Hct 42% (37% to 47%)
Day 1, Medical-Surgical Unit (5 days post-CVA):
WBC count 6,900/mm3 (5,000 to 10,000/mm3)
Hgb 16 g/dL (12 g/dL to 16 g/dL)
Hct 41% (37% to 47%)
Platelet count 310,000/mm3 (150,000 to 400,000/mm3)
Day 2, Medical-Surgical Unit (6 days post-CVA):
WBC count 7,200/mm3 (5,000 to 10,000/mm3)
Hgb 16.5 g/dL (12 g/dL to 16 g/dL)
Hct 42% (37% to 47%)
Question 5 of 5
The client is at risk for developing _ and _
Correct Answer: A,B
Rationale: The client is at risk for developing pressure injury and foot drop. Given the client's history of a recent cerebrovascular accident (CV
A) and the inability to reposition themselves, there is a heightened risk for pressure injuries due to prolonged periods of immobility. Additionally, the observed occasional movement of the left arm and leg with the right side without movement suggests a potential for muscle weakness or paralysis, which can lead to foot drop.