ATI RN
ATI Med Surg N241 Exam Questions
Extract:
Question 1 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 2 of 5
The nurse receives report for a client with acute pancreatitis on hospital day 2: NPO with NGT to low intermittent suction, VS: 110/60, 99.2°F-97- 22, 0.9% NS infusing at 125 mL/hour, and IV antibiotics have been started. Chart review reveals the following current laboratory results. Which is a priority for the nurse to report to the healthcare provider?
Correct Answer: D
Rationale: While an elevated WBC count may indicate infection, it is not unexpected in acute pancreatitis. Serum potassium within normal range does not require immediate intervention. Serum albumin within normal range does not require immediate intervention. Lipase levels significantly elevated above the normal range indicate ongoing pancreatic inflammation and may require intervention or adjustment of treatment.
Question 3 of 5
The nurse is admitting a client with the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?
Correct Answer: B
Rationale: Bradycardia is not typically associated with hepatic encephalopathy. Asterixis is a characteristic finding in hepatic encephalopathy, known as 'flapping tremor,' indicating neuromuscular irritability due to elevated blood ammonia levels. Fever is not a common direct symptom of hepatic encephalopathy. Melena indicates gastrointestinal bleeding, which while possible in liver disease, is not specific to hepatic encephalopathy.
Question 4 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 5 of 5
The nurse is preparing a community presentation about hepatitis B virus (HBV). Which information should be included in the teaching session?
Correct Answer: A
Rationale: HBV can be transmitted from an infected mother to her child during childbirth. The importance of screening and vaccination should be emphasized. While important for general health, this is not specifically related to the transmission of HBV, which is primarily spread through blood and bodily fluids. These are not typical symptoms of HBV; common symptoms include jaundice, fatigue, and abdominal pain. History of gallstones is not a risk factor for HBV.