ATI RN
Multi Dimensional Care | Final Exam
1. A nurse is assessing a client with hallux valgus. What is another term for this assessment finding?
- A. Thoracic deformity
- B. A bunion
- C. A corn
- D. Metacarpal involvement
Correct answer: B
Rationale: Hallux valgus is commonly known as a bunion, which is a bony bump that forms on the joint at the base of the big toe. A) Thoracic deformity is unrelated to hallux valgus. C) A corn is a thickened area of skin on the foot, not synonymous with hallux valgus. D) Metacarpal involvement refers to the hand, not the foot where hallux valgus occurs.
2. The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.
- A. The client complains of a sore throat
- B. The client has a temperature of 100*F
- C. The client appears drowsy following the procedure
- D. The client complains of epigastric pain
Correct answer: B
Rationale: A temperature of 100°F, epigastric pain, and hematemesis are signs that may indicate a complication related to the gastroscopy procedure.
3. A nurse is preparing to administer a dose of digoxin to a client who has heart failure. Which of the following actions should the nurse take prior to administering the medication?
- A. Monitor the client's respiratory rate.
- B. Assess the client's apical pulse.
- C. Review the client's potassium level.
- D. Monitor the client's fluid intake.
Correct answer: B
Rationale: The correct action the nurse should take prior to administering digoxin is to assess the client's apical pulse. Digoxin is known to affect the heart rate, potentially causing bradycardia. Monitoring the client's respiratory rate (Choice A) is not directly related to administering digoxin. Reviewing the client's potassium level (Choice C) is important but not a direct prerequisite for administering digoxin. Monitoring the client's fluid intake (Choice D) is also important but not a specific action to take just before administering digoxin.
4. When providing care for a patient with sickle cell crisis, what is important for the nurse to do?
- A. Monitor the patient's intake of oral and IV fluids
- B. Evaluate the effectiveness of opioid analgesics
- C. Encourage the patient to ambulate as much as tolerated
- D. Educate the patient about high-protein, high-calorie foods
Correct answer: B
Rationale: The correct answer is to evaluate the effectiveness of opioid analgesics. In sickle cell crisis, pain is the most common symptom and is usually managed with large doses of continuous opioids. Monitoring fluid intake (Choice A) is important, but limiting fluids may not be necessary. Encouraging ambulation (Choice C) is generally good but may not be the priority during a sickle cell crisis. Educating the patient about nutrition (Choice D) is important for overall health but may not be the immediate focus during a crisis.
5. The immune response is the combined work of specialized cells that neutralize or destroy __________ in the body.
- A. T cells
- B. B cells
- C. telomeres
- D. antigens
Correct answer: D
Rationale: The correct answer is D, antigens. Antigens are substances recognized by the immune system as foreign, triggering an immune response to neutralize or destroy them. In this context, T cells and B cells are specialized cells of the immune system that respond to antigens, but they are not the substances being neutralized or destroyed. Telomeres, on the other hand, are protective structures at the end of chromosomes and are not targeted for neutralization or destruction by the immune system.
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