ATI RN
ATI Perfusion Quizlet
1. An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to
- A. check all stools for occult blood
- B. encourage fluids to 3000 mL/day
- C. provide oral hygiene every 2 hours
- D. check the temperature every 4 hours
Correct answer: A
Rationale: The correct answer is to check all stools for occult blood. With a platelet count of 18,000/µL, the patient is at a high risk of spontaneous bleeding. Checking stools for occult blood can help detect any internal bleeding early. Encouraging fluids and providing oral hygiene are important interventions in general, but in this case, monitoring for bleeding takes precedence. Checking the temperature every 4 hours is not directly related to the patient's current condition and platelet count.
2. A client says to the nurse “I am worthless person, I should be dead†The nurse best replies:
- A. “Don’t say you are worthless, you are not a worthless personâ€
- B. “We are going to help you with your feelingsâ€
- C. “What makes you feel you’re worthless?â€
- D. “What you say is not trueâ€
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.
3. A nurse is caring for a client receiving theophylline for chronic obstructive pulmonary disease (COPD). Which of the following client findings indicates the need for immediate intervention?
- A. Productive cough
- B. Drowsiness
- C. Vomiting
- D. Polyuria
Correct answer: D
Rationale: Polyuria is a sign of theophylline toxicity and requires immediate intervention. Theophylline toxicity can lead to serious complications, and polyuria is a concerning symptom that indicates the need for urgent medical attention. Productive cough, drowsiness, and vomiting are common side effects of theophylline but are not typically indicative of immediate life-threatening issues like polyuria in the context of theophylline toxicity.
4. A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?
- A. The client is experiencing an aura.
- B. The client's antiseizure medication level is within the therapeutic range.
- C. The client has been seizure-free for 2 years.
- D. The client's seizure activity lasts longer than 5 minutes.
Correct answer: D
Rationale: Seizure activity lasting longer than 5 minutes requires immediate intervention as it can lead to status epilepticus, a medical emergency.
5. What symptoms would the nurse expect to see in a client with chronic obstructive pulmonary disease (COPD)?
- A. Dyspnea on exertion
- B. Normal lung sounds
- C. Normal arterial blood gases
- D. Onset of the disease during young adulthood
Correct answer: A
Rationale: The correct answer is A: Dyspnea on exertion. COPD typically manifests with symptoms like dyspnea on exertion due to impaired lung function. This symptom is a result of the airways being obstructed and the lungs not being able to expel air effectively. Choices B and C are incorrect because in COPD, abnormal lung sounds such as wheezing, crackles, or diminished breath sounds are often heard upon auscultation, and arterial blood gases are usually abnormal, showing low oxygen levels and high carbon dioxide levels. Choice D is incorrect as COPD is more commonly diagnosed in individuals over 40 who have a history of smoking or exposure to lung irritants.
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