LPN LPN
ATI Medical Surgical Proctored Exam 2019 Quizlet
1. A client in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?
- A. Administer oxygen via face mask.
- B. Notify the operating room team.
- C. Place the client in Trendelenburg.
- D. Administer a fluid bolus of 500 ml.
Correct answer: C
Rationale: In this scenario, the priority action for the nurse is to place the client in Trendelenburg position. This position helps alleviate pressure on the umbilical cord, preventing compression and ensuring continued blood flow to the fetus. Administering oxygen, notifying the operating room team, or administering a fluid bolus are not the initial priority actions in a cord prolapse situation.
2. What dietary advice should the nurse provide to help reduce the occurrence of hot flashes in a post-menopausal client?
- A. Increase intake of spicy foods.
- B. Limit caffeine and alcohol consumption.
- C. Consume a high-protein diet.
- D. Eat more dairy products.
Correct answer: B
Rationale: Limiting caffeine and alcohol consumption is recommended to help reduce the frequency of hot flashes in post-menopausal individuals. Caffeine and alcohol can trigger hot flashes and worsen their occurrence. Encouraging the client to reduce these stimulants in their diet may help alleviate hot flashes and improve their quality of life.
3. The nurse is caring for four clients: Client A, who has emphysema and an oxygen saturation of 94%; Client B, with a postoperative hemoglobin of 8.7 g/dL; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy with a white blood cell count of 15,000/mm3. What intervention should the nurse implement?
- A. Increase Client A's oxygen to 4 liters per minute via nasal cannula.
- B. Determine if Client B has two units of packed cells available in the blood bank.
- C. Ask the dietitian to add a banana to Client C's breakfast tray.
- D. Inform Client D that surgery is likely to be delayed until the infection is treated.
Correct answer: D
Rationale: A high white blood cell count, as seen in Client D, indicates infection, which may require postponing surgery to treat the infection adequately. It is crucial to address the underlying infection before proceeding with the appendectomy to prevent complications and ensure a successful surgical outcome.
4. A male client in the day room becomes increasingly angry and aggressive when denied a day-pass. Which action should the nurse implement?
- A. Tell him he can have a day pass if he calms down.
- B. Put the client's behavior on extinction.
- C. Decrease the volume on the television set.
- D. Instruct the client to sit down and be quiet.
Correct answer: D
Rationale: Instructing the client to sit down and be quiet is a direct and assertive approach that can help de-escalate the situation safely. It sets clear boundaries and expectations for the client's behavior, which may help reduce agitation and aggression in this scenario. Offering a day pass if the client calms down (Choice A) might reinforce the aggressive behavior. Putting the client's behavior on extinction (Choice B) involves not reinforcing the behavior, but it may not directly address the immediate safety concern. Decreasing the volume on the television set (Choice C) does not address the client's behavior directly and may not effectively manage the escalating situation.
5. A client with hypothyroidism is started on levothyroxine (Synthroid). Which statement by the client indicates a need for further teaching?
- A. I will take this medication every morning before breakfast.
- B. I should have my thyroid levels checked regularly.
- C. If I lose weight, I may need an increased dose.
- D. I can stop taking this medication once my symptoms improve.
Correct answer: D
Rationale: The correct answer is D. Levothyroxine is typically a lifelong therapy for hypothyroidism. It should not be discontinued even if symptoms improve because the medication helps replace the deficient thyroid hormone. Stopping the medication prematurely can lead to a recurrence of symptoms and potential complications. Patients must understand the importance of continuous levothyroxine therapy and the necessity of regular follow-up with their healthcare provider to monitor thyroid levels and adjust the dosage as needed.
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