ATI RN
ATI RN Adult Medical Surgical Online Practice 2023 A
1. A healthcare professional is monitoring a client following a thoracentesis. The healthcare professional should identify which of the following manifestations as a complication and contact the provider immediately?
- A. Serosanguineous drainage from the puncture site
- B. Discomfort at the puncture site
- C. Increased heart rate
- D. Decreased temperature
Correct answer: C: Increased heart rate
Rationale: Following a thoracentesis, it is crucial for healthcare professionals to monitor for potential complications. Increased heart rate can indicate hypovolemia or other serious issues, such as bleeding or pneumothorax, and requires immediate attention to prevent further complications. Serosanguineous drainage from the puncture site is a common expected finding post-procedure. Discomfort at the puncture site is also common and can be managed with appropriate interventions. Decreased temperature is not typically associated with complications following a thoracentesis. Therefore, the correct answer is increased heart rate as it signifies a potential serious complication that needs prompt medical evaluation.
2. A client with heart failure is receiving digoxin. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 78/min.
- B. Vision changes.
- C. Respiratory rate of 16/min.
- D. Blood pressure of 120/80 mm Hg.
Correct answer: B
Rationale: The correct answer is B: Vision changes. Vision changes are a classic sign of digoxin toxicity and should be reported immediately to the provider for further evaluation and management. A heart rate of 78/min, a respiratory rate of 16/min, and a blood pressure of 120/80 mm Hg are within normal ranges and are not typically associated with digoxin toxicity. Therefore, they would not be the priority findings to report in this situation.
3. A nurse is caring for a client prescribed ferrous sulfate for the treatment of anemia. Which of the following instructions should be included in client teaching about this medication?
- A. Take the medication on an empty stomach to maximize absorption
- B. Notify your provider if your stool becomes dark green
- C. Decrease dietary fiber intake while taking this medication
- D. Take prescribed antacids at the same time as this medication
Correct answer: A
Rationale: The correct answer is A. The nurse should instruct clients to take iron on an empty stomach, 1 hour before meals to maximize absorption. This enhances the medication's effectiveness. Option B is incorrect because dark green stool is a common side effect of iron supplements and does not necessarily indicate a problem. Option C is incorrect as dietary fiber intake does not need to be decreased while taking iron supplements. Option D is incorrect because antacids can interfere with the absorption of iron and should not be taken at the same time.
4. Which is a correct evaluation of the new psychiatric nurse's statement regarding a client's use of defense mechanisms?
- A. Defense mechanisms can be self-protective responses to stress and need not be eliminated.
- B. Defense mechanisms are a maladaptive attempt by the ego to manage anxiety and should always be eliminated.
- C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged but not eliminated.
- D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.
Correct answer: A
Rationale: The correct evaluation is that defense mechanisms can be self-protective responses to stress and do not necessarily need to be eliminated. These mechanisms serve the purpose of reducing anxiety during times of stress. While some defense mechanisms may be maladaptive, they can also help individuals cope with challenging situations. It is essential for the nurse to recognize that addressing defense mechanisms should be done sensitively, as they may be crucial for the client's emotional regulation. Encouraging the development of healthy coping skills while acknowledging the role of defense mechanisms in managing stress is a balanced approach in psychiatric care. Choice B is incorrect because completely eliminating defense mechanisms is not always feasible or beneficial. Choice C is incorrect as it oversimplifies the relationship between defense mechanisms and ego integrity. Choice D is incorrect as it misrepresents the role of defense mechanisms in ego functions.
5. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?
- A. Night sweats
- B. Low-grade fever
- C. Weight gain
- D. Blood in the sputum
Correct answer: Weight gain
Rationale:
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