ATI RN
ATI RN Custom Exams Set 4
1. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?
- A. Secure a clean container
- B. Discard the container if the outside becomes soiled
- C. Rinse the client's mouth with water after collection
- D. Tell the client that 4 tablespoons of sputum are needed
Correct answer: A
Rationale: Corrected Rationale: Before sputum collection, it is crucial to use a clean container to prevent specimen contamination. This step is essential to ensure accurate test results and to avoid introducing external particles or bacteria into the sample. Choice B is incorrect because discarding the container if the outside becomes soiled is not a standard practice before collection. Choice C is incorrect as rinsing the client's mouth with Listerine after collection can introduce unnecessary substances into the specimen. Choice D is incorrect as the amount of sputum needed should be determined by the healthcare provider, not the client.
2. Which patient is most likely to be diagnosed with complex regional pain syndrome II (CRPS II)?
- A. A patient who has experienced a spinal cord injury and reports severe, burning pain in his legs.
- B. A patient who reports severe pain in her hand following a surgery for carpal tunnel syndrome.
- C. A patient who develops pain in his foot following a fracture and immobilization with a cast.
- D. A patient who experiences chronic pain and swelling in his arm following a brachial plexus injury.
Correct answer: D
Rationale: Complex regional pain syndrome II (CRPS II) typically occurs after an injury to a peripheral nerve. In this case, a brachial plexus injury involves damage to the nerves that control muscles in the arm and hand, leading to chronic pain and swelling. Choices A, B, and C describe pain related to other conditions such as spinal cord injury, carpal tunnel surgery, and fracture immobilization, which are not typically associated with CRPS II.
3. A client who is postoperative following a colon resection reports pain. Which of the following actions should the nurse take?
- A. Assist the client in changing positions in bed
- B. Administer a PRN dose of morphine
- C. Encourage the client to use relaxation techniques
- D. Offer the client a back massage
Correct answer: B
Rationale: Administering a PRN dose of morphine is the most appropriate action to manage postoperative pain in a client following a colon resection. Morphine is a potent analgesic commonly used to relieve moderate to severe pain, especially in postoperative settings. While assisting the client to change positions in bed, encouraging relaxation techniques, and offering a back massage can provide comfort and support, they may not be sufficient in managing the pain following a major surgical procedure like a colon resection. Therefore, the priority intervention for acute postoperative pain control in this scenario is to administer medication like morphine.
4. A 43-year-old man has tested positive for systemic candidiasis, and the care team has decided on IV fluconazole as a first-line treatment. When administering this medication, the nurse should
- A. administer the drug with lactated Ringer's.
- B. infuse the drug no faster than 200 mg/h.
- C. avoid administering the drug through a peripheral IV.
- D. administer prophylactic heparin prior to the fluconazole.
Correct answer: C
Rationale: When administering IV fluconazole, the nurse should avoid administering the drug through a peripheral IV. Fluconazole is known to cause phlebitis and tissue irritation if infused through a peripheral IV line. It is recommended to administer fluconazole through a central venous catheter to reduce the risk of complications. Choices A, B, and D are incorrect as there is no specific recommendation to administer the drug with lactated Ringer's, infuse it at a particular rate, or administer prophylactic heparin prior to fluconazole in this scenario.
5. A client has a new prescription for levothyroxine. Which of the following findings should the nurse monitor for as a potential adverse effect of the medication?
- A. Increased heart rate.
- B. Weight loss.
- C. Hyperthermia.
- D. Decreased deep-tendon reflexes.
Correct answer: A
Rationale: Corrected Rationale: An increased heart rate is a common adverse effect of levothyroxine due to its role in boosting metabolism. Choice B, weight loss, is actually a therapeutic effect of levothyroxine as it helps in managing hypothyroidism by increasing the metabolic rate. Hyperthermia (Choice C) is not a typical adverse effect of levothyroxine. Decreased deep-tendon reflexes (Choice D) are not associated with levothyroxine use.