ATI LPN
Adult Medical Surgical ATI
1. The healthcare provider is preparing to administer a blood transfusion. Which action is most important to ensure client safety?
- A. Check the client's vital signs before starting the transfusion.
- B. Verify the client's identity and blood compatibility.
- C. Administer the blood with normal saline.
- D. Monitor the client for the first 15 minutes of the transfusion.
Correct answer: B
Rationale: Verifying the client's identity and blood compatibility is the most critical step in ensuring client safety during a blood transfusion. This process helps prevent transfusion reactions by confirming that the correct blood product is being administered to the right patient.
2. In a client with liver cirrhosis experiencing confusion and disorientation, what condition is most likely causing these symptoms?
- A. Hepatic encephalopathy
- B. Hypoglycemia
- C. Electrolyte imbalance
- D. Dehydration
Correct answer: A
Rationale: Hepatic encephalopathy is the most likely condition causing confusion and disorientation in a client with liver cirrhosis. This condition is a common complication of liver cirrhosis and is characterized by cognitive impairment due to elevated ammonia levels in the blood. The build-up of ammonia affects brain function, leading to symptoms such as confusion, disorientation, and altered consciousness. Hypoglycemia (choice B) may present with confusion but is less likely in a client with liver cirrhosis without a history of diabetes or insulin use. Electrolyte imbalance (choice C) and dehydration (choice D) can contribute to confusion but are not the primary causes in a client with liver cirrhosis experiencing these symptoms.
3. A client is admitted with a diagnosis of acute pancreatitis. Which laboratory value should the nurse monitor closely?
- A. Serum amylase.
- B. Serum sodium.
- C. Serum calcium.
- D. Serum potassium.
Correct answer: A
Rationale: In acute pancreatitis, serum amylase is a crucial laboratory value to monitor closely. Elevated levels of serum amylase are a key indicator of pancreatic inflammation and can help confirm the diagnosis of acute pancreatitis. Therefore, monitoring serum amylase levels is essential for assessing the progression and severity of the condition in a client with acute pancreatitis.
4. Why is a client with ascites scheduled for a paracentesis procedure?
- A. To diagnose liver disease
- B. To relieve abdominal pressure
- C. To assess kidney function
- D. To reduce blood pressure
Correct answer: B
Rationale: The correct answer is B: "To relieve abdominal pressure." Paracentesis is performed to drain accumulated fluid in the peritoneal cavity, providing symptomatic relief for clients with ascites. Choice A is incorrect because paracentesis is not a diagnostic procedure for liver disease. Choice C is incorrect as assessing kidney function would typically involve different procedures. Choice D is incorrect as paracentesis does not directly impact blood pressure.
5. The healthcare provider is caring for a patient who is taking warfarin (Coumadin). Which laboratory value should the healthcare provider monitor closely?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Hemoglobin level.
- D. White blood cell count.
Correct answer: B
Rationale: Corrected Rationale: When caring for a patient on warfarin, monitoring prothrombin time (PT) is crucial. PT helps assess the blood's ability to clot properly, ensuring the patient maintains therapeutic anticoagulation levels while minimizing bleeding risks. Platelet count (Choice A) is important but not the most critical for warfarin therapy. Hemoglobin level (Choice C) and white blood cell count (Choice D) are not directly related to monitoring the effects of warfarin.
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