ATI LPN
ATI PN Adult Medical Surgical 2019
1. The nurse is caring for a client with hyperthyroidism. Which intervention should the nurse implement to manage the client's condition?
- A. Provide a high-calorie diet.
- B. Encourage frequent rest periods.
- C. Restrict fluid intake.
- D. Administer a stool softener.
Correct answer: B
Rationale: Encouraging frequent rest periods is essential in managing hyperthyroidism as it helps address the fatigue and hypermetabolic state commonly associated with this condition. Rest is crucial to support the body's recovery and reduce the stress on the thyroid gland. While nutrition is important in managing hyperthyroidism, providing a high-calorie diet is not the priority intervention. Restricting fluid intake is not typically necessary unless there are specific indications such as heart failure. Administering a stool softener is not directly related to managing hyperthyroidism.
2. A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for the treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time?
- A. Have the client's healthcare provider write a letter to the HMO explaining the need for the transplant.
- B. Help the client place a call to the HMO to seek information about limitations of coverage.
- C. Encourage the client to contact a lawyer to file a lawsuit against the HMO if necessary.
- D. Have the social worker contact the state board of insurance to register a complaint against the HMO.
Correct answer: B
Rationale: The best action for the nurse to take in this situation is to help the client directly contact the HMO to seek information about limitations of coverage. This approach addresses the client's immediate concerns and clarifies the situation, enabling the client to understand the coverage and potential outcomes regarding the bone marrow transplant. Choice A is not the best option as having the healthcare provider write a letter may not provide immediate clarification on coverage. Choice C is inappropriate as legal action should be considered as a last resort, and choice D involving the state board of insurance is not necessary at this initial stage of addressing the client's concern.
3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client's safety?
- A. Increase the oxygen flow rate to 6 liters/minute if the client is short of breath.
- B. Instruct the client to breathe deeply and cough frequently.
- C. Use a nasal cannula to deliver oxygen at a low flow rate.
- D. Encourage the client to remove the oxygen when eating or drinking.
Correct answer: C
Rationale: Using a nasal cannula to deliver oxygen at a low flow rate is the appropriate intervention for clients with COPD receiving oxygen therapy. High flow rates can lead to respiratory depression in COPD patients. This intervention helps maintain a safe and controlled oxygen delivery to prevent potential complications associated with high oxygen flow rates.
4. The client has been prescribed metformin (Glucophage) for type 2 diabetes. Which instruction should the nurse include in discharge teaching?
- A. Take the medication at bedtime.
- B. Take the medication with meals.
- C. Take the medication on an empty stomach.
- D. Take the medication as needed for high blood sugar.
Correct answer: B
Rationale: The correct instruction for taking metformin (Glucophage) is with meals. This helps reduce gastrointestinal side effects and improves the medication's absorption. Taking it on an empty stomach can lead to more adverse effects, so it is essential to take it with food. Option A ('Take the medication at bedtime') is incorrect because metformin should be taken with meals to enhance its effectiveness and reduce side effects. Option C ('Take the medication on an empty stomach') is incorrect as taking metformin on an empty stomach can increase the likelihood of experiencing gastrointestinal issues. Option D ('Take the medication as needed for high blood sugar') is incorrect because metformin is typically taken regularly as prescribed, not just as needed for high blood sugar.
5. A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?
- A. Bounding erratic pulse.
- B. Regularly irregular pulse.
- C. Thready irregular pulse.
- D. No palpable pulse.
Correct answer: D
Rationale: Ventricular fibrillation is a life-threatening arrhythmia characterized by chaotic, asynchronous contractions of the ventricles, resulting in ineffective cardiac output. This leads to the absence of a palpable pulse. Nurses should be prepared to initiate immediate interventions such as defibrillation to restore normal cardiac rhythm in a client experiencing ventricular fibrillation.
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