ATI LPN
ATI PN Adult Medical Surgical 2019
1. A client is scheduled for a colonoscopy. Which instruction should the nurse provide?
- A. Eat a light breakfast on the day of the procedure.
- B. You will need to drink a bowel preparation solution before the procedure.
- C. Avoid all liquids for 24 hours before the procedure.
- D. You can continue taking your blood thinners until the day of the procedure.
Correct answer: B
Rationale: The correct instruction for a client scheduled for a colonoscopy is to drink a bowel preparation solution before the procedure. This solution helps cleanse the colon, ensuring clear visualization during the colonoscopy procedure. Choice A is incorrect because a light breakfast is usually recommended the day before the procedure, not on the day of the colonoscopy. Choice C is incorrect as it is important to stay hydrated and follow specific instructions regarding liquid intake. Choice D is incorrect as blood thinners may need to be adjusted or stopped before the colonoscopy to reduce the risk of bleeding during the procedure.
2. What skin care instructions should the nurse give to a patient receiving external beam radiation therapy for cancer treatment?
- A. Use a heating pad to relieve any pain in the treated area.
- B. Apply alcohol-based lotions to the treated area daily.
- C. Avoid exposing the treated area to sunlight.
- D. Wash the treated area with hot water and strong soap.
Correct answer: C
Rationale: Patients undergoing external beam radiation therapy should be advised to avoid exposing the treated area to sunlight to prevent further skin damage. Heat sources like heating pads should be avoided to prevent burns and irritation to the skin. Alcohol-based lotions can be irritating to the skin and are not recommended. Washing the treated area with lukewarm water and mild soap is preferable to maintain skin integrity and prevent irritation. Therefore, the correct instruction for the patient is to avoid exposing the treated area to sunlight.
3. What is the primary action of amlodipine when prescribed to a patient with hypertension?
- A. Increase heart rate
- B. Reduce blood pressure
- C. Lower cholesterol levels
- D. Decrease blood sugar levels
Correct answer: B
Rationale: Amlodipine is a calcium channel blocker that works by relaxing the blood vessels, leading to a reduction in blood pressure. This medication does not increase heart rate, lower cholesterol levels, or decrease blood sugar levels.
4. A patient with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). What is the priority nursing action?
- A. Administer regular insulin intravenously.
- B. Give oral hypoglycemic agents.
- C. Administer sodium bicarbonate.
- D. Provide a high-calorie diet.
Correct answer: A
Rationale: The priority nursing action for a patient with type 1 diabetes mellitus admitted with diabetic ketoacidosis (DKA) is to administer regular insulin intravenously. Insulin helps to lower blood glucose levels and correct acidosis, which are critical in managing DKA. Administering oral hypoglycemic agents is not appropriate in the acute setting of DKA as they may not work quickly enough compared to intravenous insulin. While sodium bicarbonate may be used to correct acidosis, insulin administration is the priority to address both hyperglycemia and acidosis simultaneously. Providing a high-calorie diet is not suitable initially in DKA management; the main focus is on stabilizing the patient's condition through insulin therapy and fluid/electrolyte correction.
5. A client with severe rheumatoid arthritis is experiencing joint pain and stiffness. Which intervention should the nurse implement to help relieve the client's symptoms?
- A. Apply cold packs to the affected joints.
- B. Encourage passive range-of-motion exercises.
- C. Administer a muscle relaxant.
- D. Provide a high-calorie diet.
Correct answer: B
Rationale: Encouraging passive range-of-motion exercises is the most appropriate intervention to help relieve symptoms of joint pain and stiffness in clients with severe rheumatoid arthritis. These exercises help maintain joint mobility, prevent muscle contractures, and reduce stiffness in the affected joints. Passive range-of-motion exercises can also improve circulation to the joints, promoting healing and reducing pain. Applying cold packs may help with inflammation and pain temporarily, but it does not address the long-term joint mobility issues associated with rheumatoid arthritis. Muscle relaxants are not typically indicated for managing joint pain and stiffness in rheumatoid arthritis. While nutrition is important for overall health, providing a high-calorie diet is not a direct intervention for relieving joint pain and stiffness in this context.
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