ATI RN
ATI Pathophysiology Exam 2
1. What clinical manifestations would the nurse expect to find in a client who is experiencing anaphylaxis?
- A. Dilated bronchioles, constriction of peripheral blood vessels, decreased capillary permeability
- B. Asthma, deep vein thrombosis, hepatic encephalopathy
- C. Narrowing of the bronchioles, dilation of the peripheral blood vessels, increased capillary permeability
- D. Left-sided heart failure, pulmonary embolism, urinary tract infection
Correct answer: C
Rationale: In anaphylaxis, the client would present with narrowing of the bronchioles, dilation of the peripheral blood vessels, and increased capillary permeability. These manifestations lead to symptoms such as difficulty breathing, low blood pressure, and swelling. Choices A, B, and D are incorrect because they do not describe the typical clinical manifestations of anaphylaxis.
2. The nurse is providing medication for a client with osteomyelitis. What teaching should the nurse indicate in the education?
- A. The most common adverse e effect for nonsteroidal anti-inflammatory drugs (NSAIDS)are liver failure and tinnitus
- B. The main side effect of acetaminophen is gastrointestinal GI bleeding
- C. You should not take more than 4000 mg of acetaminophen a day
- D. Nonsteroidal anti-inflammatory drugs (NSAIDS) are very safe and are known to have no side effects
Correct answer: The most common adverse e effect for nonsteroidal anti-inflammatory drugs (NSAIDS)are liver failure and tinnitus
Rationale:
3. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What is the nurse's priority action?
- A. Flush the IV line with saline
- B. Discontinue the infusion
- C. Elevate the limb
- D. Apply a cold compress
Correct answer: B
Rationale: The correct answer is to discontinue the infusion. The symptoms described - pain, redness, and warmth along the vein - are indicative of phlebitis, which is inflammation of the vein. Continuing the infusion can lead to further complications. Flushing the IV line, elevating the limb, or applying a cold compress do not address the underlying issue of phlebitis and may not be sufficient to resolve the problem. Therefore, the priority action is to discontinue the infusion to prevent worsening of the condition.
4. A client with frequent tonic-clonic seizures is being admitted. What action should the nurse add to the client's plan of care?
- A. Ensure blankets are placed on all four sides of the bed.
- B. Refrain from using restraints during seizure activity.
- C. Position the client laterally during seizure activity.
- D. Have a tongue depressor available at the client's bedside.
Correct answer: D
Rationale: The correct action the nurse should add to the client's plan of care is to have a tongue depressor available at the client's bedside. This is important during a seizure to prevent the client from biting their tongue. Placing the client laterally helps maintain a clear airway and prevents aspiration, making choice C a good practice during seizure activity. Using restraints during a seizure can cause injuries and should be avoided, making choice B incorrect. Wrapping blankets around all four sides of the bed is unnecessary for seizure management and does not contribute to the client's safety during a seizure, making choice A incorrect.
5. What is a condition where the airways become inflamed and narrow, making breathing difficult?
- A. Asthma
- B. Bronchitis
- C. Pleurisy
- D. Tuberculosis
Correct answer: A
Rationale: Asthma is the correct answer. It is a condition characterized by inflammation, narrowing, and swelling of the airways, leading to symptoms like wheezing, shortness of breath, and coughing. Bronchitis is the inflammation of the bronchial tubes; Pleurisy is inflammation of the tissues that line the lungs and chest cavity; Tuberculosis is a bacterial infection that mainly affects the lungs.
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