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Adult Medical Surgical ATI
1. A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which pre-dialysis assessment finding should the nurse report to the healthcare provider?
- A. Serum potassium of 5.5 mEq/L.
- B. Blood pressure of 180/90 mm Hg.
- C. Heart rate of 80 beats per minute.
- D. Serum sodium of 140 mEq/L.
Correct answer: B
Rationale: The correct answer is B. A blood pressure of 180/90 mm Hg is elevated and should be reported to the healthcare provider before hemodialysis. Hypertension can have a significant impact on the effectiveness and safety of the dialysis treatment. Controlling blood pressure before the procedure is crucial to prevent complications during the dialysis session.
2. 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.
3. A client with schizophrenia is prescribed haloperidol (Haldol). The nurse should monitor the client for which potential side effect?
- A. Tardive dyskinesia.
- B. Orthostatic hypotension.
- C. Photosensitivity.
- D. Hyperglycemia.
Correct answer: A
Rationale: The correct answer is A: Tardive dyskinesia. Haloperidol (Haldol) is an antipsychotic medication that can lead to tardive dyskinesia, a side effect characterized by involuntary, repetitive movements of the face and body. Monitoring for this side effect is crucial to provide timely interventions and prevent further complications.
4. 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.
5. Which regimen is most effective for treating H. pylori infection?
- A. Metronidazole, bismuth subsalicylate, amoxicillin for 14 days
- B. Clarithromycin and omeprazole for 14 days
- C. Metronidazole, lansoprazole, and clarithromycin for 14 days
- D. Metronidazole, clarithromycin, and omeprazole for 7 days
Correct answer: C
Rationale: Regimen C, which consists of metronidazole, lansoprazole, and clarithromycin for 14 days, is recommended by the FDA as an effective treatment for H. pylori infection. This regimen has been shown to have a high eradication rate and is a standard recommendation in clinical practice guidelines for the management of H. pylori-related conditions.
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