ATI RN
ATI Med Surg N241 Exam Questions
Extract:
Question 1 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.
Question 2 of 5
A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?
Correct Answer: A
Rationale: Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding. While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided. Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding. Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.
Question 3 of 5
The nurse should evaluate results of which laboratory tests while caring for a client who has cirrhosis of the liver? Select all that apply.
Correct Answer: A,B,C
Rationale: PT is prolonged in cirrhosis due to impaired synthesis of clotting factors by the liver, making it important to monitor for bleeding risk. Serum albumin levels decrease in cirrhosis due to impaired liver function, reflecting the client's nutritional status and liver synthetic function. Elevated serum ammonia levels can indicate hepatic encephalopathy, a complication of cirrhosis characterized by altered mental status. Troponin is not typically evaluated in cirrhosis assessment; it is a cardiac marker used to assess for myocardial infarction. Serum lipase is not typically evaluated in cirrhosis assessment; it is a pancreatic enzyme used to diagnose pancreatitis.
Question 4 of 5
A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?
Correct Answer: A
Rationale: Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment. The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia. This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario. While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.
Question 5 of 5
An adult client is admitted to the emergency department with symptoms of acute pancreatitis. Which data support this diagnosis?
Correct Answer: C
Rationale: These symptoms are more indicative of chronic conditions. These are not specific to acute pancreatitis. Elevated lipase and Turner's sign (bruising around the flanks) strongly suggest acute pancreatitis. Amylase within normal limits and steatorrhea do not support acute pancreatitis.