ATI LPN
ATI PN Adult Medical Surgical 2019
1. A client with osteoporosis is being discharged home. Which instruction should the nurse include in the discharge teaching?
- A. Avoid weight-bearing exercises.
- B. Take calcium supplements with meals.
- C. Limit vitamin D intake.
- D. Increase intake of caffeine-containing beverages.
Correct answer: B
Rationale: Taking calcium supplements with meals is a crucial instruction for a client with osteoporosis. Calcium absorption is enhanced when taken with food, and proper calcium intake is essential for managing osteoporosis effectively by promoting bone health and density. Avoiding weight-bearing exercises (Choice A) is incorrect because these exercises help improve bone strength. Limiting vitamin D intake (Choice C) is also incorrect as vitamin D is necessary for calcium absorption. Increasing caffeine intake (Choice D) is not recommended as caffeine can interfere with calcium absorption.
2. A patient with chronic obstructive pulmonary disease (COPD) is experiencing severe dyspnea. What position should the nurse encourage the patient to assume?
- A. Supine
- B. Prone
- C. High Fowler's
- D. Trendelenburg
Correct answer: C
Rationale: The High Fowler's position is the most appropriate position for a patient with COPD experiencing severe dyspnea. This position helps improve lung expansion and reduce dyspnea by allowing the diaphragm to move more freely and increasing the efficiency of breathing. It also helps reduce the work of breathing and enhances oxygenation in patients with COPD. Supine position (Choice A) may worsen dyspnea by limiting lung expansion. Prone position (Choice B) is not ideal for COPD patients experiencing severe dyspnea as it may restrict breathing. Trendelenburg position (Choice D) is not recommended for COPD patients with dyspnea as it can further compromise breathing.
3. A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?
- A. Bounding erratic pulse.
- B. Regularly irregular pulse.
- C. Thready irregular pulse.
- D. No palpable pulse.
Correct answer: D
Rationale: Ventricular fibrillation is a life-threatening arrhythmia characterized by chaotic, asynchronous contractions of the ventricles, resulting in ineffective cardiac output. This leads to the absence of a palpable pulse. Nurses should be prepared to initiate immediate interventions such as defibrillation to restore normal cardiac rhythm in a client experiencing ventricular fibrillation.
4. A client with severe anemia is being treated with a blood transfusion. Which assessment finding indicates a transfusion reaction?
- A. Elevated blood pressure.
- B. Fever and chills.
- C. Increased urine output.
- D. Bradycardia.
Correct answer: B
Rationale: Fever and chills are classic signs of a transfusion reaction. These symptoms indicate that the body is having a response to the transfused blood, possibly due to incompatibility or an immune reaction. Elevated blood pressure (choice A) is not a typical sign of a transfusion reaction. Increased urine output (choice C) and bradycardia (choice D) are also not characteristic signs of a transfusion reaction. It is crucial to recognize symptoms of a transfusion reaction promptly to prevent further complications and ensure appropriate management.
5. A healthcare professional is educating a group of recent nursing graduates about their risks for contracting hepatitis B. What preventative measure should the professional promote?
- A. Immunization
- B. Chronic tonsillitis
- C. Consumption of a vitamin-rich diet
- D. Annual vitamin K injections
Correct answer: A
Rationale: The correct preventative measure to promote for preventing hepatitis B infection is immunization. Healthcare workers, including nurses, are at risk of exposure to hepatitis B, and vaccination is crucial in preventing infection. Immunization, along with adherence to standard precautions such as using personal protective equipment, proper hand hygiene, and safe needle practices, plays a vital role in protecting healthcare workers from contracting hepatitis B.
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