ATI LPN
ATI PN Adult Medical Surgical 2019
1. A client with chronic kidney disease (CKD) is experiencing hyperkalemia. Which intervention should the nurse implement to address this condition?
- A. Administer calcium gluconate.
- B. Encourage a diet high in potassium.
- C. Provide potassium supplements.
- D. Restrict sodium intake.
Correct answer: A
Rationale: Administering calcium gluconate is the appropriate intervention for a client with hyperkalemia. Calcium gluconate helps stabilize the heart by counteracting the effects of high potassium levels and reducing the risk of cardiac complications in individuals with hyperkalemia. Choices B, C, and D are incorrect. Encouraging a diet high in potassium or providing potassium supplements would exacerbate hyperkalemia. Restricting sodium intake is not directly related to addressing hyperkalemia.
2. A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?
- A. Administer a Fleet enema as prescribed and remain with the client
- B. Contact the primary care provider promptly and report these signs of perforation
- C. Position the client supine and insert an NG tube
- D. Page the primary provider and report that the client may be obstructed
Correct answer: B
Rationale: In a client with acute diverticulitis experiencing sudden increase in temperature, exquisite abdominal tenderness, and uncharacteristic abdominal rigidity, these signs suggest a possible perforation. The nurse should promptly contact the primary care provider to report these signs, as perforation requires immediate medical attention to prevent further complications.
3. Which intervention should the nurse implement to enhance the efficacy of the client's asthma medication therapy?
- A. Administer the albuterol inhaler before other inhaled medications.
- B. Provide oxygen via nasal cannula at 2 liters/minute.
- C. Encourage the client to drink three liters of fluids daily.
- D. Keep the client upright during nebulizer therapy.
Correct answer: A
Rationale: Administering a bronchodilator such as albuterol as the first step is crucial to open the airways, allowing better penetration of subsequent inhaled medications and enhancing their overall efficacy in managing asthma symptoms.
4. A client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the client to describe what sign or symptom?
- A. Burning pain on swallowing
- B. Regurgitation of undigested food
- C. Symptoms mimicking a myocardial infarction
- D. Chronic parotid abscesses
Correct answer: B
Rationale: Regurgitation of undigested food is a typical symptom of esophageal diverticulum. This condition forms a pouch in the esophagus that can trap food, leading to regurgitation of undigested food. The other options are not typically associated with esophageal diverticulum.
5. Which problem in a client requires the most immediate intervention by the nurse?
- A. Finger paresthesias related to carpal tunnel syndrome.
- B. Increasing sharp pain related to compartment syndrome.
- C. Increasing burning pain related to a Morton's neuroma.
- D. Increasing sharp pain related to plantar fasciitis.
Correct answer: B
Rationale: The correct answer is B: Increasing sharp pain related to compartment syndrome. Compartment syndrome is a serious condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. Immediate intervention is crucial to prevent permanent damage to muscles and nerves, including tissue necrosis and nerve injury. Choices A, C, and D do not present the same level of urgency as compartment syndrome, making them less critical for immediate intervention. Carpal tunnel syndrome, Morton's neuroma, and plantar fasciitis may cause discomfort and functional limitations but are not typically considered emergencies requiring urgent intervention like compartment syndrome.
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