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ATI Adult Medical Surgical
1. A patient with schizophrenia is prescribed olanzapine. What is an important side effect for the healthcare provider to monitor?
- A. Hypertension
- B. Weight gain
- C. Hypoglycemia
- D. Bradycardia
Correct answer: B
Rationale: The correct answer is B: Weight gain. Olanzapine, an atypical antipsychotic, is known to cause significant weight gain and metabolic syndrome. It is crucial for healthcare providers to closely monitor patients for these side effects to prevent complications and provide appropriate interventions.
2. The healthcare provider is caring for a client with Guillain-Barré syndrome. Which assessment finding requires the healthcare provider's immediate action?
- A. Loss of deep tendon reflexes.
- B. Ascending weakness.
- C. New onset of confusion.
- D. Decreased vital capacity.
Correct answer: D
Rationale: Decreased vital capacity is the most critical assessment finding in a client with Guillain-Barré syndrome as it indicates respiratory compromise. This requires immediate intervention to ensure adequate ventilation and prevent respiratory failure, a common complication of this syndrome. Monitoring and maintaining respiratory function are vital in these clients to prevent complications such as respiratory distress, hypoxia, and respiratory failure. Loss of deep tendon reflexes and ascending weakness are typical manifestations of Guillain-Barré syndrome but do not require immediate action compared to compromised respiratory function. New onset of confusion may be a concern but is not as immediately life-threatening as decreased vital capacity.
3. A client with portal hypertension who has developed ascites is scheduled for a paracentesis. What pre-procedure nursing intervention is essential?
- A. Encourage the client to empty the bladder
- B. Administer a laxative to clear the bowels
- C. Restrict the client's fluid intake
- D. Place the client in a supine position
Correct answer: A
Rationale: Emptying the bladder before a paracentesis is essential to prevent bladder injury during the procedure. A full bladder may be in the path of the needle insertion, increasing the risk of bladder puncture. Encouraging the client to empty the bladder ensures their safety and reduces the likelihood of complications.
4. A client with coronary artery disease (CAD) is prescribed atorvastatin (Lipitor). Which laboratory value requires immediate intervention?
- A. Total cholesterol of 180 mg/dL.
- B. Low-density lipoprotein (LDL) of 200 mg/dL.
- C. Triglycerides of 150 mg/dL.
- D. High-density lipoprotein (HDL) of 40 mg/dL.
Correct answer: B
Rationale: An LDL level of 200 mg/dL is significantly elevated and requires immediate intervention to reduce the risk of cardiovascular events in a client with coronary artery disease (CAD). High LDL levels contribute to the development and progression of atherosclerosis, which can lead to complications like heart attacks and strokes. Lowering LDL levels is a key goal in managing CAD and preventing further cardiovascular damage. Total cholesterol of 180 mg/dL, triglycerides of 150 mg/dL, and HDL of 40 mg/dL are within acceptable ranges and do not pose an immediate risk that necessitates urgent intervention.
5. What is the primary action of a short-acting beta2-agonist (SABA) prescribed to a patient with an acute asthma exacerbation?
- A. Reduce inflammation
- B. Relieve bronchospasm
- C. Thin respiratory secretions
- D. Suppress cough
Correct answer: B
Rationale: The correct answer is B: Relieve bronchospasm. The primary action of short-acting beta2-agonists (SABAs) is to relieve bronchospasm. These medications are bronchodilators that work by opening the airways, making breathing easier for patients experiencing asthma exacerbations. By relieving bronchospasm, SABAs help improve airflow and alleviate symptoms of asthma such as wheezing and shortness of breath. Choices A, C, and D are incorrect because SABAs do not primarily reduce inflammation, thin respiratory secretions, or suppress cough. While these actions may be part of asthma management, the immediate goal of using a SABA during an acute exacerbation is to quickly relieve bronchospasm and improve airflow.
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