LPN LPN
ATI Adult Medical Surgical
1. While assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse notes her deep tendon reflexes are 1+, respiratory rate is 12 breaths/minute, urinary output is 90 ml in 4 hours, and magnesium sulfate level is 9 mg/dl. What intervention should the nurse implement based on these findings?
- A. Continue the magnesium sulfate infusion as prescribed.
- B. Decrease the magnesium sulfate infusion by one-half.
- C. Stop the magnesium sulfate infusion immediately.
- D. Administer calcium gluconate immediately.
Correct answer: C
Rationale: The nurse should stop the magnesium sulfate infusion immediately in a client with preeclampsia exhibiting diminished reflexes, respiratory depression, and low urinary output, which indicate magnesium sulfate toxicity. This action is crucial to prevent further complications and adverse effects on the client.
2. A patient with chronic pain is prescribed a fentanyl patch. What is the most important instruction for the nurse to provide?
- A. Apply the patch to a different site each time.
- B. Change the patch every 72 hours.
- C. Avoid using additional heating pads over the patch.
- D. Remove the patch before showering.
Correct answer: B
Rationale: The most important instruction for the nurse to provide to a patient prescribed a fentanyl patch is to change the patch every 72 hours. This ensures consistent pain control and prevents complications. It is crucial to rotate the application sites to prevent skin irritation or reactions. Using additional heating pads over the patch should be avoided as it can increase the absorption of the medication, leading to overdose or adverse effects. Removing the patch before showering is not necessary as long as the patch is securely in place.
3. A client with peptic ulcer disease is prescribed ranitidine (Zantac). Which statement by the client indicates the need for further teaching?
- A. I will take this medication at bedtime.
- B. I need to avoid smoking while taking this medication.
- C. I should take this medication with meals.
- D. This medication will help reduce stomach acid.
Correct answer: C
Rationale: The client's statement that they should take ranitidine with meals indicates a need for further teaching. Ranitidine is typically taken at bedtime or before meals to be most effective in reducing stomach acid. Taking it with meals may not provide the optimal therapeutic effect.
4. While assessing a 70-year-old female client with Alzheimer's disease, the nurse notes deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care?
- A. Apply a moisturizing cream to the affected areas.
- B. Encourage the client to consume foods rich in vitamin B.
- C. Notify the healthcare provider for further evaluation.
- D. Ensure that the client gets adequate B vitamins in foods or supplements.
Correct answer: D
Rationale: Cracks at the corners of the mouth, known as angular cheilitis, can be a sign of vitamin B deficiency, specifically B2 (riboflavin) or B3 (niacin). The nurse should ensure that the client receives adequate B vitamins through foods rich in these nutrients or supplements to address the deficiency, which can help improve the condition of the client's mouth.
5. A patient with chronic heart failure is prescribed furosemide. What is the primary action of this medication?
- A. Increase cardiac output
- B. Reduce fluid retention
- C. Decrease heart rate
- D. Lower blood pressure
Correct answer: B
Rationale: Furosemide is a loop diuretic that acts by inhibiting sodium and chloride reabsorption in the loop of Henle, leading to increased diuresis. By reducing fluid retention, furosemide helps decrease the workload on the heart in patients with chronic heart failure. This medication does not directly increase cardiac output, decrease heart rate, or lower blood pressure as its primary action.
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