ATI RN
ATI Med Surg N241 Exam Questions
Extract:
Question 1 of 5
The client with cirrhosis is at risk for developing complications. Which condition is the most serious and potentially life-threatening?
Correct Answer: A
Rationale: These are dilated veins in the esophagus that can rupture and lead to life-threatening bleeding. While concerning and indicative of hepatic encephalopathy, it is not immediately life-threatening like a variceal bleed. Indicates poor nutritional status and liver function but is not as acutely dangerous as bleeding varices. This is a concern but does not represent an immediate life-threatening condition like esophageal varices.
Question 2 of 5
When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?
Correct Answer: C
Rationale: Monitoring for hypertension is not directly related to caring for a client with enteral feeding via a jejunostomy tube. Measuring residual volume is a nursing intervention for clients with gastric feeding tubes, not jejunostomy tubes. Diarrhea is a potential complication of enteral feeding, and monitoring stool output is essential to assess for this complication and adjust feeding accordingly. Monitoring blood glucose levels is important for clients with diabetes but is not specific to caring for a client with enteral feeding via a jejunostomy tube.
Question 3 of 5
A client with cirrhosis is scheduled to receive a third dose of lactulose (Cephulac) at 1800. Which current finding would cause the nurse to question administering this medication?
Correct Answer: D
Rationale: Breath with fecal odor could indicate hepatic encephalopathy, for which lactulose is indicated. Increasing confusion is a symptom of hepatic encephalopathy suggests a need for lactulose. Elevated ammonia levels indicate hepatic encephalopathy hence the need for lactulose. If the client already has diarrhea, additional doses of lactulose (which acts as a laxative) could exacerbate this condition and might need to be adjusted or halted based on clinical judgment.
Question 4 of 5
The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?
Correct Answer: D
Rationale: Requesting a dietary consult is useful but not the most immediate action needed. Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance. Fluid restriction may be considered but not before addressing the electrolyte issues. Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.
Question 5 of 5
When planning care for a client with acute pancreatitis, which order would the nurse anticipate that will contribute to pain control?
Correct Answer: B
Rationale: Pancreatic enzymes are typically used to aid in digestion rather than pain control in acute pancreatitis. Decompression of the gastrointestinal tract through nasogastric suction can help reduce pancreatic stimulation and alleviate pain in acute pancreatitis. While ambulation may help prevent complications, it is not directly related to pain control in acute pancreatitis. A clear liquid diet may be initiated once the acute phase has resolved, but it does not directly contribute to pain control.