ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A nurse is caring for a client with rheumatoid arthritis who has been taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?
- A. Weight loss
- B. Hypoglycemia
- C. Hypertension
- D. Hyperkalemia
Correct answer: C
Rationale: The correct answer is C, 'Hypertension.' Prednisone, a corticosteroid, can lead to hypertension as an adverse effect. Prednisone can cause sodium retention and potassium loss, leading to increased blood pressure. Weight loss (choice A) is not a common adverse effect of prednisone; in fact, weight gain is more common. Hypoglycemia (choice B) is not typically associated with prednisone use; instead, hyperglycemia is a common concern. Hyperkalemia (choice D) is also unlikely with prednisone use; instead, hypokalemia is a potential electrolyte imbalance.
2. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration?
- A. Pitting edema of bilateral lower extremities
- B. Hypoactive bowel sounds in all four quadrants
- C. Weight is the same as the day before
- D. Bilateral posterior lung sounds are diminished
Correct answer: A
Rationale: The correct answer is A: Pitting edema of bilateral lower extremities. Pitting edema can indicate fluid overload, which is a potential complication of TPN administration. Choice B, hypoactive bowel sounds, is more indicative of a gastrointestinal issue rather than a complication of TPN. Choice C, weight remaining the same, is expected to remain stable with proper TPN administration. Choice D, diminished lung sounds, is not directly related to TPN administration and is more suggestive of a respiratory issue.
3. A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?
- A. Contact precautions
- B. Airborne precautions
- C. Droplet precautions
- D. Protective environment
Correct answer: B
Rationale: Tuberculosis is spread through small droplets measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client who has TB under airborne precautions to prevent the spread of microbes. Choice A, contact precautions, are used for diseases spread by direct or indirect contact. Choice C, droplet precautions, are for diseases spread by larger droplets. Choice D, protective environment, is used for immunocompromised clients to protect them from environmental pathogens.
4. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?
- A. After stroking the lateral area of the foot, the client's toes contract and draw together
- B. After hip flexion, the client is unable to extend their leg completely without pain
- C. The client's voluntary movement is not coordinated
- D. The client reports pain and stiffness when flexing their neck
Correct answer: B
Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding suggests meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, Choice C refers to coordination deficits, and Choice D indicates neck pain and stiffness, which are not related to Kernig's sign.
5. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?
- A. The dressing was changed 7 days ago
- B. The circumference of the client's upper arm has increased by 10%
- C. The catheter has not been used in 8 hours
- D. The catheter has been flushed with 10 mL of sterile saline after medication use
Correct answer: B
Rationale: An increase in the circumference of the client's upper arm by 10% could indicate deep vein thrombosis, which is a serious condition. Deep vein thrombosis can impede blood flow and potentially lead to life-threatening complications. Therefore, the nurse should notify the provider immediately about this finding. Choice A is not an immediate concern as PICC dressing changes are usually done every 7 days. Choice C is a normal finding as catheters may not be used for certain periods. Choice D is a correct procedure for maintaining catheter patency after medication use.
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $149.99