LPN LPN
ATI Adult Medical Surgical
1. A client with heart failure is prescribed furosemide (Lasix). Which instruction should the nurse include in the client's teaching plan?
- A. Take the medication before bedtime.
- B. Report any weight gain of more than 2 pounds in a day.
- C. Increase your intake of high-sodium foods.
- D. Limit your fluid intake to less than 1 liter per day.
Correct answer: B
Rationale: In heart failure, fluid retention is a concern. Furosemide helps manage this by promoting diuresis. Instructing the client to report weight gain exceeding 2 pounds in a day is crucial as it can indicate fluid accumulation, prompting timely intervention to prevent worsening heart failure symptoms and complications.
2. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement?
- A. Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath.
- B. Administer the aspirin with at least two ounces of water or juice.
- C. Notify the healthcare provider if the child complains of ringing in the ears.
- D. Advise the parents to question the child about seeing yellow halos around objects.
Correct answer: C
Rationale: In children, ringing in the ears (tinnitus) can be a sign of aspirin toxicity. Aspirin toxicity can be particularly concerning in children and can lead to serious complications. Therefore, it is crucial for the nurse to prioritize monitoring for signs of aspirin toxicity, such as tinnitus, and promptly notify the healthcare provider if such symptoms occur.
3. What should be monitored to evaluate the effectiveness of enoxaparin in a patient with deep vein thrombosis (DVT)?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct answer: C
Rationale: The international normalized ratio (INR) is the appropriate parameter to monitor the effectiveness of enoxaparin in preventing clot formation in patients with deep vein thrombosis (DVT). INR reflects the clotting ability of the blood and is commonly used to assess the therapeutic range of anticoagulant medications, such as enoxaparin, which is crucial in managing and preventing thrombotic events like DVT.
4. Following a CVA, the nurse assesses that a client has developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?
- A. Continuous tube feeding at 65 ml/hr via gastrostomy.
- B. Total parenteral nutrition to be infused at 125 ml/hour.
- C. Nasogastric tube connected to low intermittent suction.
- D. Metoclopramide (Reglan) intermittent piggyback.
Correct answer: A
Rationale: In a client with dysphagia and gastrointestinal symptoms such as hypoactive bowel sounds and a firm, distended abdomen, continuous tube feeding might exacerbate the symptoms. This can lead to complications and should be questioned by the nurse.
5. When should the charge nurse intervene based on the observed behavior?
- A. Two staff members are overheard talking about a cure for AIDS outside a client's room.
- B. A hospital transporter is reading a client's history and physical while waiting for an elevator.
- C. A UAP tells a client, 'It's hard to quit drinking but Alcoholics Anonymous helped me.'
- D. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge.
Correct answer: B
Rationale: The hospital transporter reading a client's history and physical without a legitimate need violates patient confidentiality. This behavior requires immediate intervention to protect the client's privacy and confidentiality rights.
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