Questions 168

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ATI Med Surg Nursing 300 day Exam Questions

Extract:


Question 1 of 5

A patient is to receive a bolus of Heparin 20 units/kg. The patient weighs 121 Ibs. The medication is supplied as 25,000 units/250 mL. How many Ml will the nurse give? (round to the nearest whole number)

Correct Answer: 11

Rationale: For 55 kg (121 lbs ÷ 2.2), 20 units/kg = 1100 units; 1100 units × 250 mL ÷ 25,000 units = 11 mL.

Question 2 of 5

A client presents to the Emergency Department (ED) complaining of a 'racing' heart and nervousness. The client also admits to a history of cocaine abuse. The cardiac monitor displays the rhythm below. Which nursing intervention should the nurse perform?

Correct Answer: D

Rationale: Initial assessment of vital signs and stability is critical before interventions, especially with cocaine-related tachycardia.

Question 3 of 5

The nurse is caring for a client receiving a heparin infusion for disseminated intravascular coagulation (DIC). Which of the following lab results would indicate a sub-therapeutic level? An activated partial thromboplastin time (aPTT) of :(normal value: 25-35 seconds)

Correct Answer: D

Rationale: An aPTT of 69 seconds is above normal but likely below the therapeutic range (1.5-2.5 times normal) for heparin in DIC.

Question 4 of 5

The client has developed graft versus host disease (GVHD) during treatment for acute lymphoblastic leukemia (ALL). The client has a generalized pruritic rash on the trunk and the extremities. What nursing measures should the nurse use to address this problem?

Correct Answer: B,C,D

Rationale: B: Antihistamines relieve itching. C: Cool water and mild soap soothe skin. D: Clipping nails and using lotions prevent scratching and moisturize skin. A is incorrect as bacitracin is for infections, not GVHD rash.

Question 5 of 5

A client was recently diagnosed with lung cancer. The nurse is evaluating discharge teaching with the client. Which statement about lung cancer indicates that teaching was effective?

Correct Answer: C

Rationale: Pacing activities conserves energy, reflecting effective teaching for lung cancer management.

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