the nurse is caring for pa4ent in the cardiac unit recovering from a cardiac bypass grah procedure the pa4ent9s spouse comes out to the hallway and ex
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Nursing Elites

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ATI Perfusion Questions

1. The nurse is caring for a patient in the cardiac unit recovering from a cardiac bypass graft procedure. The patient's spouse comes out to the hallway and expresses concern about the patient's confusion since surgery was 3 days ago. An appropriate response by the nurse would be:

Correct answer: C

Rationale: Choice C is the correct answer because confusion can be a common occurrence after cardiac surgeries due to factors such as anesthesia, medication, and the stress of the procedure. By acknowledging the spouse's concern and explaining that confusion is a known potential outcome, the nurse provides reassurance and education. Choices A, B, and D are incorrect because they do not directly address the spouse's concern about the patient's confusion or provide appropriate information about the situation.

2. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of

Correct answer: C

Rationale: The correct answer is C: cobalamin (vitamin B12). Methotrexate can lead to a deficiency in cobalamin, resulting in megaloblastic anemia. Therefore, increasing the oral intake of cobalamin is essential to address this deficiency. Choice A, iron, is incorrect because megaloblastic anemia caused by methotrexate is not typically due to iron deficiency. Choice B, folic acid, is also incorrect as methotrexate does not directly cause folic acid deficiency. Choice D, ascorbic acid (vitamin C), is incorrect as it is not directly related to megaloblastic anemia caused by methotrexate; instead, cobalamin is the key vitamin that needs attention.

3. During a physical assessment, the nurse examines the lymph nodes of a patient. Which assessment finding would be of most concern to the nurse?

Correct answer: A

Rationale: The correct answer is A. A 2-cm nontender supraclavicular node is of most concern because enlarged and nontender nodes in this area are highly suggestive of malignancies such as lymphoma. Choice B is less concerning as a 1-cm mobile and nontender axillary node is usually benign. Choice C, an inability to palpate any superficial lymph nodes, could be due to factors like obesity or edema, but it is not necessarily a cause for immediate concern. Choice D, firm inguinal nodes in a patient with an infected foot, may indicate a local reaction to infection rather than a systemic issue related to malignancy.

4. A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?

Correct answer: A

Rationale: In the case of a patient with pancytopenia of unknown origin, a bone marrow biopsy is usually indicated to determine the cause. A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. Abdominal ultrasound (Choice B) is not typically used to diagnose pancytopenia. A Complete Blood Count (CBC) (Choice C) is a routine blood test and does not require a specific consent form. Activated Partial Thromboplastin Time (aPTT) (Choice D) is a coagulation test and not typically performed to diagnose pancytopenia.

5. Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis?

Correct answer: C

Rationale: The correct answer is C: 'Avoid exposure to crowds when possible.' This instruction is crucial in discharge teaching for a patient admitted with a sickle cell crisis because exposure to crowds increases the risk of infection, which is the most common cause of sickle cell crisis. Choices A, B, and D are incorrect. Taking a daily multivitamin with iron (Choice A) may be beneficial for some individuals but is not specifically related to managing sickle cell crisis. Limiting fluids to 2 to 3 quarts per day (Choice B) is not typically recommended for patients with sickle cell crisis, as adequate hydration is important. Drinking only two caffeinated beverages daily (Choice D) is not a priority instruction in managing sickle cell crisis.

Similar Questions

Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the healthcare provider?
A patient is considering options to manage his/her coronary artery disease. The nurse explains a coronary artery bypass graft procedure will:
A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states:
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?
A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?

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