ATI RN
ATI Pathophysiology Exam 2
1. In which of the following patients may the administration of a live vaccine be contraindicated?
- A. Patient with renal insufficiency
- B. Patient with hepatic failure
- C. Patient taking steroid therapy
- D. Patient over the age of 65 years
Correct answer: C
Rationale: The correct answer is C. The administration of live vaccines may be contraindicated in patients taking steroid therapy. Steroids can suppress the immune system, reducing the effectiveness of live vaccines. Patients with renal insufficiency or hepatic failure can typically receive live vaccines as these conditions are not direct contraindications. Age alone, such as being over 65 years old, is not a contraindication for live vaccines unless there are other specific health considerations. Therefore, the patient taking steroid therapy is the most likely candidate for whom the administration of a live vaccine would be contraindicated.
2. What is the priority action for a patient experiencing chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Administer aspirin
- C. Obtain IV access
- D. Check cardiac enzymes
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This medication helps to dilate the blood vessels, reduce the workload on the heart, and improve blood flow to the heart muscle, providing immediate relief for chest pain in acute coronary syndrome. Administering aspirin is also crucial in the early management of acute coronary syndrome to prevent further clot formation. However, in terms of immediate symptom relief, nitroglycerin takes precedence over aspirin. Obtaining IV access is important for administering medications and fluids but is not the priority over providing immediate relief for chest pain. Checking cardiac enzymes is essential for diagnosing acute coronary syndrome but is not the immediate priority when a patient is experiencing chest pain.
3. What health instruction will enhance regulation of a colostomy (defecation) of clients?
- A. Irrigate after lunch everyday
- B. Eat fruits and vegetables in all three meals
- C. Eat balanced meals at regular intervals
- D. Restrict exercise to walking only
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
4. When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?
- A. 10-15 seconds
- B. 30-35 seconds
- C. 20-25 seconds
- D. 0-5 seconds
Correct answer: D
Rationale: During endotracheal suctioning, the nurse should apply suctioning while withdrawing and gently rotating the catheter 360 degrees for a short period of 0-5 seconds. This brief duration helps minimize the risk of hypoxia and trauma to the airway. Choices A, B, and C suggest longer time periods for suctioning, which can increase the risk of complications such as hypoxia, mucosal damage, and the removal of excess amounts of airway secretions.
5. When providing teaching for a child prescribed ferrous sulfate, which of the following instructions should the nurse include?
- A. Take with meals
- B. Take at bedtime
- C. Take with a glass of milk
- D. Take with a glass of orange juice
Correct answer: D
Rationale: The correct answer is D, 'Take with a glass of orange juice.' Ferrous sulfate is best absorbed with vitamin C, making orange juice the preferred choice. Choices A, B, and C are incorrect because taking ferrous sulfate with meals, at bedtime, or with milk can reduce its absorption due to interactions with food components like calcium, inhibiting the iron absorption process.
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