a nurse is assessing a client who had a myocardial infarction upon auscultating heart sounds the nurse hears the following sound what action by the nu a nurse is assessing a client who had a myocardial infarction upon auscultating heart sounds the nurse hears the following sound what action by the nu
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?

Correct answer: A

Rationale: The sound described is an S3 heart sound, which can indicate heart failure. The next appropriate action for the provider is to listen to the client's lung sounds. Lung sounds can provide additional information about the client's condition, especially when abnormal heart sounds are present. Calling the Rapid Response Team is not warranted based solely on the heart sound assessment. Having the client sit upright is not directly related to addressing the abnormal heart sound.

2. When attempting to determine a teenager's mental health resilience, what assessment question should the nurse ask that is not applicable?

Correct answer: D

Rationale: Assessing a teenager's mental health resilience involves exploring coping mechanisms, support systems, and attitudes towards seeking help. Option D is not relevant to assessing resilience but rather focuses on the comparison between seeking advice from a counselor versus the nurse, which doesn't directly gauge the teenager's resilience.

3. Which statement made by a patient prescribed bupropion (Wellbutrin) demonstrates that the medication education the patient received was effective?

Correct answer: A

Rationale: Choice A is the correct answer because it shows that the patient understands the dual benefits of bupropion (Wellbutrin) in treating depression and aiding in smoking cessation. Bupropion is commonly prescribed for these reasons as it has a lower risk of weight gain compared to other antidepressants. Choices B, C, and D are not the most appropriate because they do not specifically reflect the benefits or key information related to bupropion therapy.

4. What should the nurse include in patient education regarding the effectiveness of oral contraceptives?

Correct answer: C

Rationale: The correct answer is C. Oral contraceptives can be less effective when taken with certain antibiotics due to potential drug interactions that may reduce contraceptive efficacy. It is crucial for patients to be aware of this to consider additional contraceptive measures when prescribed antibiotics. Choice A is incorrect because while oral contraceptives are highly effective when taken correctly, they are not 100% foolproof. Choice B is incorrect as oral contraceptives may take some time to reach their full effectiveness after starting. Choice D is also incorrect as taking oral contraceptives with food does not significantly affect their efficacy.

5. When starting therapy with raloxifene, a client should monitor for which of the following adverse effects?

Correct answer: B

Rationale: The correct answer is B: Hot flashes. When initiating therapy with raloxifene, clients should be advised to monitor for hot flashes as they are a common adverse effect associated with this medication. Hot flashes are a well-known side effect of raloxifene due to its action on estrogen receptors. Leg cramps (Choice A), urinary frequency (Choice C), and hair loss (Choice D) are not typically associated with raloxifene therapy. Therefore, monitoring for hot flashes is crucial to manage and address this common side effect appropriately.

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