ATI LPN
ATI Adult Medical Surgical
1. A patient with severe pain is prescribed morphine sulfate. What is the most important side effect for the nurse to monitor?
- A. Diarrhea
- B. Hypertension
- C. Respiratory depression
- D. Increased urine output
Correct answer: C
Rationale: When a patient is prescribed morphine sulfate, the most critical side effect for the nurse to monitor is respiratory depression. Morphine can suppress the respiratory drive, leading to inadequate ventilation and potentially life-threatening consequences. Monitoring the patient's respiratory status closely is essential to promptly identify and manage any signs of respiratory depression.
2. A client is receiving chemotherapy and is at risk for neutropenia. Which precaution should the nurse implement?
- A. Encourage regular visitors to boost morale.
- B. Ensure the client receives live vaccines.
- C. Place the client in a private room.
- D. Provide a diet high in fresh fruits and vegetables.
Correct answer: C
Rationale: Placing the client in a private room is crucial to protect them from infections due to their compromised immune system. Neutropenia, a common side effect of chemotherapy, decreases white blood cell count, making the client more susceptible to infections. By placing the client in a private room, exposure to pathogens from other individuals is minimized, reducing the risk of infection and helping maintain the client's health during this vulnerable period.
3. What instruction should a patient with a history of hypertension be provided when being discharged with a prescription for a thiazide diuretic?
- A. Avoid foods high in potassium.
- B. Take the medication at bedtime.
- C. Monitor weight daily.
- D. Limit fluid intake to 1 liter per day.
Correct answer: C
Rationale: The correct instruction for a patient with a history of hypertension being discharged with a prescription for a thiazide diuretic is to monitor weight daily. This is important because thiazide diuretics can cause fluid imbalances, and monitoring weight daily can help detect significant changes early. Choice A, avoiding foods high in potassium, is not directly related to thiazide diuretics. Choice B, taking the medication at bedtime, may vary depending on the specific medication but is not a universal instruction. Choice D, limiting fluid intake to 1 liter per day, is not appropriate as adequate hydration is important to prevent complications like hypokalemia.
4. During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?
- A. Heel stick glucose of 65 mg/dL.
- B. Head circumference of 35 cm (14 inches).
- C. Widened, tense, bulging fontanel.
- D. High-pitched shrill cry.
Correct answer: C
Rationale: A widened, tense, bulging fontanel is a critical finding in a newborn as it can indicate increased intracranial pressure. This condition requires immediate attention and intervention to prevent further complications. Monitoring fontanel status is crucial in assessing the newborn's neurological well-being and ensuring early detection of potential issues.
5. A patient with schizophrenia is prescribed olanzapine. What is an important side effect for the healthcare provider to monitor?
- A. Hypertension
- B. Weight gain
- C. Hypoglycemia
- D. Bradycardia
Correct answer: B
Rationale: The correct answer is B: Weight gain. Olanzapine, an atypical antipsychotic, is known to cause significant weight gain and metabolic syndrome. It is crucial for healthcare providers to closely monitor patients for these side effects to prevent complications and provide appropriate interventions.
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