ATI RN
ATI Pathophysiology Exam 1
1. A client is brought to the emergency department after a motor vehicle accident in which she suffered a spinal cord injury at the level of C5. Which of the following assessments should be the priority?
- A. Monitoring urinary output
- B. Monitoring heart rate and rhythm
- C. Monitoring respiratory rate
- D. Monitoring the client's pain levels
Correct answer: B
Rationale: The correct answer is monitoring heart rate and rhythm. With a C5 spinal cord injury, monitoring heart rate and rhythm is crucial as it can impact autonomic regulation. This level of injury can affect cardiac function due to the disruption of sympathetic nerve fibers. Monitoring urinary output may be important to assess for urinary retention, but it is not the priority in this scenario. While monitoring respiratory rate is essential in all patients, in this case, cardiovascular stability takes precedence. Pain management is important but is not the priority when assessing a client with a C5 spinal cord injury.
2. A drug ending in the suffix (tidine) is considered a ______.
- A. Antidepressant
- B. Protease inhibitor
- C. Beta antagonist
- D. H antagonist
Correct answer: D
Rationale: Drugs ending in -tidine are histamine (H2) receptor antagonists, which block the action of histamine at the H2 receptors, commonly used to reduce stomach acid production. Therefore, the correct answer is an 'H antagonist.' It is essential to be familiar with drug suffixes as they can provide clues to the drug's class and function.
3. If the child does not have ear problem, using IMCI, what should you as the nurse do?
- A. Check for ear discharge
- B. Check for tender swellings behind the ear
- C. Check for ear pain
- D. Go to the next question, check for malnutrition
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
4. A nurse is caring for a client who has a prescription for spironolactone. Which of the following laboratory values should the nurse monitor?
- A. Sodium 140 mEq/L
- B. Calcium 9.5 mg/dL
- C. Potassium 5.2 mEq/L
- D. Magnesium 2.0 mEq/L
Correct answer: C
Rationale: The correct answer is C: Potassium 5.2 mEq/L. A potassium level of 5.2 mEq/L is elevated and should be monitored in clients taking spironolactone, which is a potassium-sparing medication. Monitoring potassium levels is crucial as spironolactone can cause hyperkalemia. Choices A, B, and D are incorrect because sodium, calcium, and magnesium levels are not typically affected by spironolactone. Therefore, the nurse should primarily focus on monitoring the potassium levels in this scenario.
5. A client with Preeclampsia is receiving Magnesium Sulfate IV continuous infusion. Which of the following findings should the nurse report to the provider?
- A. 2+ deep tendon reflexes
- B. 2+ pedal edema
- C. 24 mL/hr urinary output
- D. Respirations 12/min
Correct answer: C
Rationale: In a client receiving Magnesium Sulfate IV for Preeclampsia, a urinary output less than 25 to 30 mL/hr indicates magnesium sulfate toxicity and should be reported to the provider for further evaluation and management. Choice A, 2+ deep tendon reflexes, is a normal finding with magnesium sulfate therapy. Choice B, 2+ pedal edema, is expected in clients with preeclampsia but does not indicate magnesium sulfate toxicity. Choice D, respirations 12/min, is within the normal range and not a concerning finding related to magnesium sulfate administration.
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