ATI LPN
ATI PN Adult Medical Surgical 2019
1. A client with a history of hypertension is prescribed lisinopril (Prinivil). Which side effect should the nurse monitor for?
- A. Dry cough.
- B. Weight gain.
- C. Tachycardia.
- D. Hyperglycemia.
Correct answer: A
Rationale: The correct answer is A: Dry cough. Lisinopril is an ACE inhibitor, and a common side effect of ACE inhibitors is a dry cough. This occurs due to the accumulation of bradykinin in the lungs, leading to irritation and subsequent cough. It is important for the nurse to monitor the client for this side effect as it can affect adherence to the medication regimen. Weight gain, tachycardia, and hyperglycemia are not typically associated with lisinopril. Therefore, choices B, C, and D are incorrect.
2. A client with acute pancreatitis is admitted to the hospital. What is the priority nursing intervention for this client?
- A. Administering oral pancreatic enzymes
- B. Encouraging a high-protein diet
- C. Maintaining NPO status and administering IV fluids
- D. Providing a low-fat diet
Correct answer: C
Rationale: The priority nursing intervention for a client with acute pancreatitis is to maintain NPO (nothing by mouth) status and administer IV fluids. This approach helps rest the pancreas, decrease pancreatic stimulation, and prevent further exacerbation of the condition. By withholding oral intake and providing IV fluids, the pancreas is given the opportunity to recover and inflammation can be reduced. This intervention is crucial in the acute phase of pancreatitis to support the healing process and prevent complications.
3. Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy?
- A. Client denies allergies to contrast media.
- B. Skin prep to insertion site completed.
- C. On-call sedation administered.
- D. Oxygen at 2 L/minute via nasal cannula.
Correct answer: C
Rationale: Administering on-call sedation is crucial before a bronchoscopy to ensure the client is comfortable and adequately prepared for the procedure. Sedation helps reduce anxiety, discomfort, and ensures the client remains still during the bronchoscopy, enabling the healthcare provider to perform the procedure effectively.
4. The client with a history of heart failure is taking furosemide (Lasix). Which laboratory result should the nurse monitor closely?
- A. Serum sodium.
- B. Serum potassium.
- C. Serum calcium.
- D. Serum magnesium.
Correct answer: B
Rationale: Furosemide (Lasix) is a loop diuretic that can lead to potassium loss, causing hypokalemia. Monitoring serum potassium levels is crucial to prevent complications such as cardiac dysrhythmias associated with low potassium levels.
5. A client who underwent a total hip replacement is receiving discharge teaching from a nurse. Which instruction should the nurse include?
- A. Avoid crossing your legs at the knees.
- B. Sit only in low chairs for comfort.
- C. Bend at the waist to pick up objects.
- D. Sleep on the affected side to prevent discomfort.
Correct answer: A
Rationale: The correct instruction the nurse should include is to avoid crossing the legs at the knees. This advice helps prevent dislocation of the new hip joint, which is a common concern after a total hip replacement surgery. Crossing the legs can place stress on the hip joint and increase the risk of dislocation. It is important for the client to follow this precaution to promote proper healing and reduce complications postoperatively.
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