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ATI Adult Medical Surgical
1. A patient with chronic obstructive pulmonary disease (COPD) is prescribed tiotropium. What is the primary purpose of this medication?
- A. Reduce mucus production
- B. Relieve bronchospasm
- C. Suppress cough
- D. Thin respiratory secretions
Correct answer: B
Rationale: Tiotropium is a long-acting bronchodilator used to relieve bronchospasm and improve airflow in patients with chronic obstructive pulmonary disease (COPD). It works by relaxing the muscles around the airways, leading to bronchodilation and improved breathing, making it an essential treatment in managing COPD symptoms.
2. A client is admitted with diabetic ketoacidosis (DKA). Which assessment finding requires immediate intervention?
- A. Fruity breath odor.
- B. Blood glucose of 450 mg/dL.
- C. Deep, rapid respirations.
- D. Serum potassium of 5.2 mEq/L.
Correct answer: C
Rationale: The correct answer is C: Deep, rapid respirations (Kussmaul breathing). This is a sign of severe acidosis commonly seen in diabetic ketoacidosis (DKA) and requires immediate intervention. Kussmaul breathing helps to compensate for the metabolic acidosis by blowing off carbon dioxide. Prompt intervention is necessary to prevent further deterioration and potential respiratory failure. Fruity breath odor (Choice A) is a classic sign of DKA but does not require immediate intervention. While a blood glucose level of 450 mg/dL (Choice B) is high, it does not pose an immediate threat to the client's life. Serum potassium of 5.2 mEq/L (Choice D) is slightly elevated but not the most critical finding that requires immediate intervention in this scenario.
3. A client with a history of asthma is prescribed salmeterol (Serevent). Which instruction should the nurse provide?
- A. Use this medication for acute asthma attacks.
- B. Use this medication before using your albuterol inhaler.
- C. Use this medication twice daily for long-term control.
- D. Use this medication as needed for wheezing.
Correct answer: C
Rationale: The correct instruction for a client prescribed salmeterol (Serevent) is to use it twice daily for long-term control. Salmeterol is a long-acting bronchodilator that is not intended for acute asthma attacks or as-needed use for wheezing. Choice A is incorrect because salmeterol is not used for acute asthma attacks. Choice B is incorrect as salmeterol is not meant to replace the albuterol inhaler but rather used for long-term control. Choice D is incorrect because salmeterol should not be used as needed; it is a maintenance medication for asthma.
4. The healthcare professional is caring for a client with a chest tube following a thoracotomy. Which assessment finding requires immediate intervention?
- A. Continuous bubbling in the water seal chamber.
- B. Serosanguineous drainage in the collection chamber.
- C. Intermittent bubbling in the suction control chamber.
- D. Chest tube secured to the client's chest wall.
Correct answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which requires immediate intervention to prevent complications such as pneumothorax. An air leak can lead to ineffective lung expansion, respiratory distress, and compromised gas exchange. Therefore, prompt action is necessary to maintain the integrity of the closed drainage system and prevent further complications. Choices B, C, and D are incorrect because serosanguineous drainage is an expected finding post-thoracotomy, intermittent bubbling in the suction control chamber is normal, and having the chest tube secured to the client's chest wall is essential for stability and proper functioning.
5. The client is prescribed clozapine (Clozaril), and the nurse plans to educate them about its purpose. Which statement should the nurse provide?
- A. It will help you function better in the community.
- B. The medication will help you think more clearly.
- C. You will be able to cope with your symptoms.
- D. It will improve your grooming and hygiene.
Correct answer: B
Rationale: Clozapine (Clozaril) is an antipsychotic medication that is known to improve cognitive function and thought clarity in individuals with schizophrenia. It primarily helps in managing symptoms related to thought processes rather than focusing on community function, coping with symptoms, or grooming and hygiene.
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