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ATI Medical Surgical Proctored Exam 2019 Quizlet
1. A highly successful individual presents to the community mental health center complaining of sleeplessness and anxiety over their financial status. What action should the nurse take to assist this client in diminishing their anxiety?
- A. Encourage them to initiate daily rituals.
- B. Reinforce the reality of their financial situation.
- C. Direct them to drink a glass of red wine at bedtime.
- D. Teach them to limit sugar and caffeine intake.
Correct answer: D
Rationale: Teaching the individual to limit sugar and caffeine intake is an appropriate intervention to reduce anxiety and improve sleep quality. Sugar and caffeine can exacerbate anxiety symptoms and disrupt sleep patterns. By reducing their intake, the individual may experience a decrease in anxiety levels and better sleep. Encouraging daily rituals, reinforcing financial realities, or suggesting alcohol consumption before bed are not evidence-based strategies for managing anxiety and sleeplessness.
2. A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority?
- A. Apply a hypothermia unit to stabilize core temperature.
- B. Increase the client's IV fluid rate to 200 ml/hr.
- C. Call the hospital chaplain to counsel the family.
- D. Draw blood cultures x3 to detect infection.
Correct answer: B
Rationale: The correct answer is to increase the client's IV fluid rate to 200 ml/hr. The client's vital signs indicate signs of shock and hypovolemia, making fluid resuscitation the priority to address these conditions. Improving intravascular volume is crucial to stabilize the client's blood pressure, heart rate, and urine output, ultimately improving organ perfusion and addressing the underlying issue of hypovolemia.
3. The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. What response should the nurse provide this mother?
- A. The child can be around other children but should wear a mask at all times.
- B. The child will no longer be contagious, no need to take any further precautions.
- C. Make sure there are no children under the age of 6 months around the infected child.
- D. Do not expose other children. RSV is very contagious even without direct oral contact.
Correct answer: D
Rationale: The correct response is to advise the mother not to expose other children to the infected child. RSV is highly contagious, and transmission can occur even without direct oral contact. It is crucial to prevent the spread of the virus to protect other children from getting infected.
4. The client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?
- A. Discontinue the IV and apply pressure at the site.
- B. Decrease the saline to a keep-open rate.
- C. Increase the rate of the current IV solution.
- D. Change the IV fluid to 0.45% normal saline at the same rate.
Correct answer: B
Rationale: In this scenario, the client is showing signs of fluid overload with tachypnea and a high pulse rate. Decreasing the saline to a keep-open rate is appropriate to prevent further fluid volume excess. This action allows for IV access to be maintained while reducing the fluid administered, helping to manage the symptoms of fluid overload.
5. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating?
- A. Administer sargramostim (Leukine, Prokine).
- B. Infuse PRBC and platelet transfusions.
- C. Give parenteral prophylactic antibiotics.
- D. Maintain a protective isolation environment.
Correct answer: D
Rationale: Maintaining a protective isolation environment is crucial during the repopulation of bone marrow post-transplant to reduce the risk of infections. The client's immune system is compromised during this period, making them highly susceptible to infections. By implementing protective isolation measures, the nurse can help prevent exposure to pathogens, safeguarding the client's health and supporting the success of the transplantation.
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