a nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hou
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Nursing Elites

ATI LPN

Medical Surgical ATI Proctored Exam

1. A client with a newly created ileostomy has not had ostomy output for the past 12 hours and reports worsening nausea. What is the nurse's priority action?

Correct answer: B

Rationale: The nurse's priority action in this situation is to report signs and symptoms of possible obstruction to the healthcare provider. Lack of ostomy output and worsening nausea can indicate a potential obstruction, which requires immediate attention and intervention to prevent complications.

2. A client who is receiving heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. What action should the nurse take?

Correct answer: B

Rationale: An activated partial thromboplastin time (aPTT) of 90 seconds is elevated, indicating a risk of bleeding. The appropriate action for the nurse is to notify the healthcare provider. Increasing the heparin infusion rate can further elevate the aPTT, leading to an increased risk of bleeding. Applying pressure to the injection site is not relevant in this situation. Administering protamine sulfate is used to reverse the effects of heparin in cases of overdose or bleeding, but it is not the initial action for an elevated aPTT.

3. A 65-year-old woman presents with difficulty swallowing, weight loss, and a history of long-standing heartburn. She has been on proton-pump inhibitors for years, but her symptoms have worsened. What is the most likely diagnosis?

Correct answer: B

Rationale: The presentation of difficulty swallowing, weight loss, and worsening symptoms despite long-term use of proton-pump inhibitors raises suspicion for esophageal cancer, especially in a patient with a history of chronic heartburn. Esophageal cancer should be considered in this scenario due to the concerning symptoms and lack of improvement despite appropriate medical management.

4. What instruction should the nurse give regarding the administration of alendronate to a patient with osteoporosis?

Correct answer: C

Rationale: The correct instruction for administering alendronate to a patient with osteoporosis is to take the medication with a full glass of water first thing in the morning. It is important for the patient to remain upright for at least 30 minutes after taking the medication to prevent esophageal irritation. Taking alendronate with milk, lying down after intake, or taking it before bedtime can reduce the medication's effectiveness or increase the risk of side effects.

5. A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which side effect should the nurse monitor for?

Correct answer: D

Rationale: The correct answer is D: Hyperglycemia. Risperidone (Risperdal) can lead to metabolic side effects, such as hyperglycemia, which requires monitoring. Choice A, Hypertension, is incorrect because risperidone is not typically associated with hypertension. Choice B, Weight loss, is less common with risperidone use as it can lead to weight gain. Choice C, Hyperactivity, is not a common side effect of risperidone; instead, it is more known for sedative effects.

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