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ATI Adult Medical Surgical
1. A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?
- A. Bounding erratic pulse.
- B. Regularly irregular pulse.
- C. Thready irregular pulse.
- D. No palpable pulse.
Correct answer: D
Rationale: Ventricular fibrillation is a life-threatening arrhythmia characterized by chaotic, asynchronous contractions of the ventricles, resulting in ineffective cardiac output. This leads to the absence of a palpable pulse. Nurses should be prepared to initiate immediate interventions such as defibrillation to restore normal cardiac rhythm in a client experiencing ventricular fibrillation.
2. A client is being treated with an antidepressant for major depressive disorder. Which statement by the client indicates a need for further teaching?
- A. I know it may take several weeks before I start feeling better.
- B. I should avoid drinking alcohol while taking this medication.
- C. I will stop taking the medication as soon as I feel better.
- D. I should take the medication at the same time every day.
Correct answer: C
Rationale: Choice C indicates a need for further teaching because stopping antidepressants abruptly can lead to withdrawal symptoms. It is essential for the client to follow the healthcare provider's instructions and complete the full course of medication even if they start feeling better to prevent potential relapse or withdrawal effects.
3. A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?
- A. Glasgow Coma Scale
- B. Assess pulses, paresthesia, and paralysis distal to the right knee
- C. Assess pulses, paresthesia, and paralysis proximal to the right knee
- D. Optic nerve using an ophthalmoscope
Correct answer: B
Rationale: In this scenario, the nurse should assess pulses, paresthesia, and paralysis distal to the right knee to evaluate for neurovascular compromise. This assessment helps determine the perfusion and sensation of the lower extremity, which is crucial in identifying potential vascular or nerve damage that may be causing the client's symptoms.
4. What should the nurse include in patient teaching for a patient prescribed ceftriaxone for bacterial pneumonia?
- A. Take the medication as prescribed.
- B. Expect urine color changes.
- C. Complete the full course of the antibiotic.
- D. Avoid dairy products during treatment.
Correct answer: C
Rationale: When educating a patient prescribed ceftriaxone for bacterial pneumonia, it is crucial to emphasize completing the full course of the antibiotic. Completing the full course helps ensure the infection is completely eradicated and reduces the risk of antibiotic resistance. Incomplete courses of antibiotics can lead to treatment failure and the development of resistant bacterial strains. Therefore, it is essential for patients to adhere to the prescribed treatment regimen to achieve optimal outcomes.
5. A client with hypothyroidism is prescribed levothyroxine (Synthroid). Which instruction should the nurse provide?
- A. Take the medication with a meal.
- B. Take the medication at bedtime.
- C. Take the medication on an empty stomach.
- D. Take the medication with an antacid.
Correct answer: C
Rationale: The correct instruction for a client prescribed levothyroxine (Synthroid) is to take the medication on an empty stomach. This ensures optimal absorption of levothyroxine. Taking it with a meal can interfere with absorption due to food interactions. Taking it at bedtime may lead to inconsistent absorption as it should be taken at the same time every day in the morning. Taking it with an antacid can reduce the absorption of levothyroxine, making it less effective.
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