ATI RN
ATI Community Health Nursing Ch 7
1. Paralysis of all or part of the trunk, legs, and pelvic organs is referred to as:
- A. Hemiplegia
- B. Tetraplegia
- C. Paraplegia
- D. Hemiparesis
Correct answer: C: Paraplegia
Rationale: Paraplegia is the paralysis of the lower half of the body, including both legs and often the trunk and pelvic organs. Hemiplegia refers to paralysis affecting one side of the body, while tetraplegia involves paralysis of all four limbs and the trunk. Hemiparesis is a partial weakness affecting one side of the body.
2. A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?
- A. Monitoring urine output
- B. Checking blood glucose levels
- C. Assessing for chest pain
- D. Monitoring electrolyte levels
Correct answer: C
Rationale: Assessing for chest pain is crucial in post-MI clients as it can indicate complications such as reinfarction or ischemia.
3. A nurse is teaching a prenatal class about infection. Which statement by the client indicates further teaching is required?
- A. I can visit someone with chickenpox 5 days after the sores crust.
- B. I should avoid eating foods that contain high folic acid.
- C. I can clean my cat's litter box during pregnancy.
- D. I should wash my hands with hot water for 10 seconds after gardening.
Correct answer: C
Rationale: The correct answer is C because cleaning a cat's litter box during pregnancy can increase the risk of toxoplasmosis, which can be harmful to the developing fetus. Choice A is correct as the statement indicates understanding of the chickenpox transmission timeline. Choice B is also correct as high folic acid foods are beneficial during pregnancy. Choice D is correct as washing hands with hot water after gardening helps prevent infections.
4. A nurse reviewing a client's medical record notes a new prescription for verifying the trough level of the client's medication. Which of the following actions should the nurse take?
- A. Obtain a blood specimen immediately prior to administering the next dose of medication.
- B. Verify that the client has been taking the medication for 24 hours before obtaining a blood specimen.
- C. Ask the client to provide a urine specimen after the next dose of medication.
- D. Administer the medication and obtain a blood specimen 30 minutes later.
Correct answer: A
Rationale: To verify the trough levels of a medication accurately, the nurse should obtain a blood specimen immediately before administering the next dose of the medication. The trough level represents the lowest concentration of the medication in the bloodstream, typically right before the next dose is due. This timing ensures an accurate assessment of the drug's concentration in the body at its lowest point, aiding in determining the drug's effectiveness and potential toxicity levels. Choice B is incorrect because waiting for 24 hours would not provide the trough level. Choice C is incorrect as urine specimens are not used to measure trough levels. Choice D is incorrect as obtaining a blood specimen 30 minutes after administering the medication would not reflect the trough level.
5. When administering enoxaparin (Lovenox) to a client for DVT prophylaxis, what is the most important lab value to monitor?
- A. Platelet count
- B. PT/INR
- C. aPTT
- D. Hemoglobin
Correct answer: A
Rationale: The correct answer is A: Platelet count. When administering enoxaparin (Lovenox) for DVT prophylaxis, it is crucial to monitor the platelet count as enoxaparin can lead to thrombocytopenia, a decrease in platelet levels. Monitoring the platelet count helps in early detection of this potential adverse effect. Choices B, C, and D are incorrect because PT/INR, aPTT, and hemoglobin levels are not the most important lab values to monitor specifically for enoxaparin administration and DVT prophylaxis.
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