ATI LPN
Adult Medical Surgical ATI
1. A client is receiving chemotherapy and is at risk for neutropenia. Which precaution should the nurse implement?
- A. Encourage regular visitors to boost morale.
- B. Ensure the client receives live vaccines.
- C. Place the client in a private room.
- D. Provide a diet high in fresh fruits and vegetables.
Correct answer: C
Rationale: Placing the client in a private room is crucial to protect them from infections due to their compromised immune system. Neutropenia, a common side effect of chemotherapy, decreases white blood cell count, making the client more susceptible to infections. By placing the client in a private room, exposure to pathogens from other individuals is minimized, reducing the risk of infection and helping maintain the client's health during this vulnerable period.
2. When implementing patient teaching for a patient admitted with hyperglycemia and newly diagnosed diabetes mellitus scheduled for discharge the second day after admission, what is the priority action for the nurse?
- A. Instruct about the increased risk of cardiovascular disease.
- B. Provide detailed information about dietary glucose control.
- C. Teach glucose self-monitoring and medication administration.
- D. Give information about the effects of exercise on glucose control.
Correct answer: C
Rationale: The priority action for the nurse when time is limited is to focus on essential teaching. In this scenario, the patient should be educated on how to self-monitor glucose levels and administer medications to control glucose levels. This empowers the patient with immediate skills for managing their condition. Instructing about the increased risk of cardiovascular disease (choice A) is important but not as urgent as teaching self-monitoring and medication administration. Providing detailed information about dietary glucose control (choice B) can be beneficial but is secondary to ensuring the patient can monitor and manage their glucose levels. Teaching about the effects of exercise (choice D) is relevant but not as critical as immediate self-monitoring and medication administration education.
3. The client with newly diagnosed hypertension is being taught about lifestyle modifications. Which recommendation should be made?
- A. Increase your intake of saturated fats.
- B. Limit your alcohol intake to two drinks per day.
- C. Engage in at least 150 minutes of moderate exercise per week.
- D. Use table salt liberally to season your food.
Correct answer: C
Rationale: Engaging in at least 150 minutes of moderate exercise per week is a key lifestyle modification recommended for individuals with hypertension. Regular exercise helps manage blood pressure, improve cardiovascular health, and overall well-being. It is important for the client to adopt a healthy lifestyle to control hypertension and reduce the risk of complications.
4. A client who has been receiving treatment for depression with a selective serotonin reuptake inhibitor (SSRI) reports experiencing decreased libido. What is the best response by the nurse?
- A. Decreased libido is a common side effect of SSRIs and may improve over time.
- B. I will notify your healthcare provider to discuss possible medication changes.
- C. You should take your medication with food to reduce side effects.
- D. Increase your daily exercise to help manage this side effect.
Correct answer: B
Rationale: When a client reports experiencing decreased libido while taking SSRIs, it is important for the nurse to notify the healthcare provider to discuss potential medication adjustments. This side effect can significantly impact a client's quality of life, and addressing it promptly by involving the healthcare provider is crucial in providing holistic care. Choices A, C, and D do not directly address the issue of decreased libido caused by SSRIs. Simply waiting for improvement over time, altering the administration of medication with food, or increasing exercise are not appropriate strategies for managing this specific side effect.
5. The client is receiving intravenous (IV) morphine for pain control. Which assessment finding requires the most immediate intervention?
- A. Drowsiness.
- B. Itching.
- C. Nausea.
- D. Respiratory rate of 8 breaths per minute.
Correct answer: D
Rationale: A respiratory rate of 8 breaths per minute indicates severe respiratory depression, a life-threatening side effect of opioid therapy. Immediate intervention is crucial to prevent respiratory failure. Monitoring and managing respiratory status are critical in clients receiving opioids to prevent adverse events. Drowsiness, itching, and nausea are common side effects of morphine but are not as immediately life-threatening as severe respiratory depression.
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