ATI RN
ATI Pathophysiology Exam
1. When evaluating the success of adding raltegravir to the drug regimen of a 42-year-old female patient with HIV, which laboratory value should the nurse prioritize?
- A. The patient's C-reactive protein levels
- B. The patient's erythrocyte sedimentation rate (ESR)
- C. The patient's viral load
- D. The patient's CD4 count
Correct answer: C
Rationale: The correct answer is C: The patient's viral load. In HIV management, monitoring the viral load is crucial to assess the effectiveness of antiretroviral therapy. A decrease in viral load indicates the treatment's success in controlling the HIV infection. Choices A, B, and D are less relevant in this context. C-reactive protein levels and erythrocyte sedimentation rate are markers of inflammation and non-specific indicators of infection, not specifically for HIV. CD4 count is important but not as immediate for evaluating the response to the newly added medication compared to monitoring the viral load.
2. A client diagnosed with schizophrenia is receiving discharge teaching. Which of the following instructions should the healthcare provider include? Select one that does not apply.
- A. Continue taking medications as prescribed
- B. Avoid all social interactions
- C. Report any side effects of medications to the healthcare provider
- D. Develop a daily routine
Correct answer: B
Rationale: Discharge instructions for a client diagnosed with schizophrenia should focus on promoting medication adherence, monitoring and reporting any medication side effects, and establishing a structured daily routine to support stability and well-being. Encouraging the client to avoid all social interactions is not appropriate as social support can be beneficial for individuals with schizophrenia. Social interactions can help reduce feelings of isolation, improve overall well-being, and provide emotional support. Therefore, advising the client to avoid all social interactions would not be in the best interest of their recovery and management of the condition.
3. A nurse works on an oncology unit and delegates personal hygiene to assistive personnel (AP). What action by the AP requires intervention from the nurse?
- A. Allowing a very tired client to skip oral hygiene and sleep.
- B. Assisting clients with washing the perianal area every 12 hours.
- C. Helping the client use a soft-bristled toothbrush for oral care.
- D. Reminding the client to rinse the mouth with water or saline.
Correct answer: A
Rationale: Skipping oral hygiene is not appropriate for a client, even if they are tired, as it increases the risk of infection.
4. What is the best way to assess for fluid overload in a patient with heart failure?
- A. Check daily weight
- B. Check blood pressure
- C. Monitor heart sounds
- D. Assess for jugular vein distention
Correct answer: A
Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.
5. A client has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
- A. Continuous bubbling in the water-seal chamber
- B. Occasional bubbling in the water-seal chamber
- C. Constant bubbling in the suction-control chamber
- D. Fluctuations in the fluid level in the water-seal chamber
Correct answer: Continuous bubbling in the water-seal chamber
Rationale: Continuous bubbling in the water-seal chamber indicates air is leaking into the pleural space, which is a complication. The water-seal chamber should have intermittent bubbling during normal functioning. Occasional bubbling in the water-seal chamber is normal and shows the system is working as intended. Constant bubbling in the suction-control chamber suggests an issue with the suction control. Fluctuations in the fluid level in the water-seal chamber are an expected finding.
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