ATI RN
ATI Perfusion Quizlet
1. A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?
- A. Bone marrow biopsy
- B. Abdominal ultrasound
- C. Complete blood count (CBC)
- D. Activated partial thromboplastin time (aPTT)
Correct answer: A
Rationale: In the case of a patient with pancytopenia of unknown origin, a bone marrow biopsy is usually indicated to determine the cause. A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. Abdominal ultrasound (Choice B) is not typically used to diagnose pancytopenia. A Complete Blood Count (CBC) (Choice C) is a routine blood test and does not require a specific consent form. Activated Partial Thromboplastin Time (aPTT) (Choice D) is a coagulation test and not typically performed to diagnose pancytopenia.
2. A client is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 90/min
- B. Temperature of 37.1°C (98.8°F)
- C. Serosanguineous wound drainage
- D. Urine output of 25 mL/hr
Correct answer: D
Rationale: A urine output of 25 mL/hr is a sign of oliguria, which may indicate dehydration or kidney impairment and should be reported. A heart rate of 90/min is within the normal range (60-100/min) for adults at rest and may be expected postoperatively. A temperature of 37.1°C (98.8°F) is within the normal range (36.1-37.2°C or 97-99°F) and does not indicate an immediate concern. Serosanguineous wound drainage is a common finding postoperatively and indicates a normal healing process.
3. The nurse is administering digoxin to a client with a heart rate of 45 bpm. What is the nurse’s priority action?
- A. Hold the digoxin and notify the healthcare provider.
- B. Administer the digoxin as ordered.
- C. Increase the dose of digoxin.
- D. Monitor the client’s heart rate and reassess in 30 minutes.
Correct answer: A
Rationale: The correct answer is to hold the digoxin and notify the healthcare provider. A heart rate of 45 bpm is already low, and digoxin can further decrease the heart rate, leading to serious complications like bradycardia or heart block. Administering the medication can exacerbate the bradycardia, hence it should be withheld. Increasing the dose of digoxin is contraindicated due to the client's low heart rate. Monitoring the heart rate alone without taking immediate action to withhold the medication is not the priority when faced with the risk of further lowering the heart rate.
4. What is the fundamental difference between nursing diagnoses and collaborative problems?
- A. Collaborative problems are managed by nurses using physician-prescribed interventions.
- B. Collaborative problems can be addressed by independent nursing interventions.
- C. Physician-prescribed interventions are incorporated into nursing diagnoses.
- D. Nursing diagnoses include physiologic complications that nurses monitor to detect status changes.
Correct answer: B
Rationale: The correct answer is B, as collaborative problems necessitate the collective expertise and skills of numerous healthcare professionals, including nurses. These problems can be dealt with through independent nursing interventions in cooperation with other team members. Option A is incorrect because collaborative problems aren't strictly managed with physician-prescribed interventions. Option C is incorrect because nursing diagnoses aim at identifying and treating actual or potential health issues, rather than merely integrating physician-prescribed interventions. Option D is incorrect because nursing diagnoses aim at identifying patient issues, not solely physiologic complications, and guide the necessary nursing care, not just monitor for changes.
5. A client has a new prescription for Warfarin. Which of the following statements by the client indicates a need for further teaching?
- A. I will avoid eating large amounts of green leafy vegetables.
- B. I will take my medication at the same time every day.
- C. I will increase my intake of foods high in potassium.
- D. I will report any signs of bleeding to my provider.
Correct answer: C
Rationale: The correct answer is C because Warfarin interacts with vitamin K, not potassium. Therefore, the client needs to be cautious with foods high in vitamin K, such as green leafy vegetables, rather than foods high in potassium. Choices A, B, and D are correct statements regarding Warfarin therapy and do not indicate a need for further teaching.
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