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ATI Medical Surgical Proctored Exam 2019 Quizlet
1. A client with schizophrenia is prescribed haloperidol (Haldol). The nurse should monitor the client for which potential side effect?
- A. Tardive dyskinesia.
- B. Orthostatic hypotension.
- C. Photosensitivity.
- D. Hyperglycemia.
Correct answer: A
Rationale: The correct answer is A: Tardive dyskinesia. Haloperidol (Haldol) is an antipsychotic medication that can lead to tardive dyskinesia, a side effect characterized by involuntary, repetitive movements of the face and body. Monitoring for this side effect is crucial to provide timely interventions and prevent further complications.
2. What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?
- A. Administer an antiemetic before starting the chemotherapy.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Keep the head of the bed elevated until the treatment is completed.
- D. Monitor the client's intravenous site hourly during the treatment.
Correct answer: D
Rationale: Monitoring the intravenous site hourly is essential to identify early signs of extravasation, such as swelling or pain, which can help prevent tissue damage. Prompt detection allows for immediate intervention, minimizing the risk of serious complications associated with vesicant extravasation.
3. Which client's laboratory value requires immediate intervention by a nurse?
- A. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7 grams.
- B. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl yesterday.
- C. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.
- D. A client with cancer who has an absolute neutrophil count < 500 today and had 2,000 yesterday.
Correct answer: D
Rationale: The correct answer is D. A sudden drop in neutrophil count to below 500 indicates severe neutropenia, putting the client at high risk for infections. Neutrophils are essential for fighting off infections, and a significant decrease in their count can compromise the client's immune response. Immediate intervention is necessary to prevent the development of serious infections in the client with neutropenia.
4. The healthcare provider is caring for a client with a chest tube. Which assessment finding requires immediate intervention?
- A. Intermittent bubbling in the water seal chamber.
- B. Drainage of 75 ml in the first hour post-insertion.
- C. Crepitus around the insertion site.
- D. Fluctuation of the water level in the water seal chamber with respiration.
Correct answer: C
Rationale: Crepitus (subcutaneous emphysema) around the insertion site can indicate air leakage, requiring immediate intervention to prevent complications such as pneumothorax. This assessment finding suggests that there may be a break in the chest tube system, leading to air entering the pleural space. Prompt intervention is crucial to prevent respiratory compromise and further complications.
5. Which intervention should the nurse implement to enhance the efficacy of the client's asthma medication therapy?
- A. Administer the albuterol inhaler before other inhaled medications.
- B. Provide oxygen via nasal cannula at 2 liters/minute.
- C. Encourage the client to drink three liters of fluids daily.
- D. Keep the client upright during nebulizer therapy.
Correct answer: A
Rationale: Administering a bronchodilator such as albuterol as the first step is crucial to open the airways, allowing better penetration of subsequent inhaled medications and enhancing their overall efficacy in managing asthma symptoms.
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