ATI LPN
Medical Surgical ATI Proctored Exam
1. The client is receiving intravenous vancomycin. Which assessment finding should the nurse report immediately?
- A. Red man syndrome.
- B. Blood pressure of 130/80 mm Hg.
- C. Mild itching at the IV site.
- D. Nausea and vomiting.
Correct answer: A
Rationale: Red man syndrome is a severe and potentially life-threatening reaction to vancomycin characterized by flushing, rash, and hypotension. Immediate intervention is required to prevent further complications such as anaphylaxis. Therefore, the nurse should report this finding immediately to ensure prompt treatment and prevent serious adverse effects.
2. A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct answer: C
Rationale: Stage 3 hepatic encephalopathy is characterized by confusion, difficulty arousing from sleep, and rigidity of extremities. These symptoms indicate advanced manifestations of hepatic encephalopathy, requiring prompt intervention and monitoring to prevent further neurological deterioration.
3. 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.
4. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?
- A. Is unable to feel sensation in the arms and hands.
- B. Has flaccid upper and lower extremities.
- C. Blood pressure is 110/70 and the apical pulse is 68.
- D. Respirations are shallow, labored, and 14 breaths/minute.
Correct answer: D
Rationale: Respirations that are shallow, labored, and at 14 breaths/minute indicate potential respiratory compromise, which is a critical situation requiring immediate intervention to maintain adequate oxygenation and prevent respiratory failure.
5. While assessing a 70-year-old female client with Alzheimer's disease, the nurse notes deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care?
- A. Apply a moisturizing cream to the affected areas.
- B. Encourage the client to consume foods rich in vitamin B.
- C. Notify the healthcare provider for further evaluation.
- D. Ensure that the client gets adequate B vitamins in foods or supplements.
Correct answer: D
Rationale: Cracks at the corners of the mouth, known as angular cheilitis, can be a sign of vitamin B deficiency, specifically B2 (riboflavin) or B3 (niacin). The nurse should ensure that the client receives adequate B vitamins through foods rich in these nutrients or supplements to address the deficiency, which can help improve the condition of the client's mouth.
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