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ATI Adult Medical Surgical
1. A patient with severe pain is prescribed morphine sulfate. What is the most important side effect for the nurse to monitor?
- A. Diarrhea
- B. Hypertension
- C. Respiratory depression
- D. Increased urine output
Correct answer: C
Rationale: When a patient is prescribed morphine sulfate, the most critical side effect for the nurse to monitor is respiratory depression. Morphine can suppress the respiratory drive, leading to inadequate ventilation and potentially life-threatening consequences. Monitoring the patient's respiratory status closely is essential to promptly identify and manage any signs of respiratory depression.
2. Why is a client with ascites scheduled for a paracentesis procedure?
- A. To diagnose liver disease
- B. To relieve abdominal pressure
- C. To assess kidney function
- D. To reduce blood pressure
Correct answer: B
Rationale: The correct answer is B: "To relieve abdominal pressure." Paracentesis is performed to drain accumulated fluid in the peritoneal cavity, providing symptomatic relief for clients with ascites. Choice A is incorrect because paracentesis is not a diagnostic procedure for liver disease. Choice C is incorrect as assessing kidney function would typically involve different procedures. Choice D is incorrect as paracentesis does not directly impact blood pressure.
3. What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?
- A. Administer an antiemetic before starting the chemotherapy.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Keep the head of the bed elevated until the treatment is completed.
- D. Monitor the client's intravenous site hourly during the treatment.
Correct answer: D
Rationale: Monitoring the intravenous site hourly is essential to identify early signs of extravasation, such as swelling or pain, which can help prevent tissue damage. Prompt detection allows for immediate intervention, minimizing the risk of serious complications associated with vesicant extravasation.
4. When should surgical correction of hypospadias typically occur for a newborn infant as advised by the nurse?
- A. Repair should be done within one month to prevent bladder infections.
- B. Repairs should typically be done before the child is potty-trained.
- C. Delaying the repair until school age reduces castration fears.
- D. To form a proper urethra repair, it should be done after sexual maturity.
Correct answer: B
Rationale: Surgical repair of hypospadias is recommended to be performed before the child is potty-trained to prevent complications. Early correction helps in achieving better outcomes and reduces the risk of issues related to urination and development of the genitalia.
5. The nurse has completed the admission assessment of a client and has determined that the client's body mass index (BMI) is 33.5 kg/m2. What health promotion advice should the nurse provide to the client?
- A. It would be very helpful if you could integrate more physical activity into your routine.
- B. You're considered to be overweight, so you should be diligent about maintaining a healthy diet.
- C. You might want to consider some of the surgical options that have been developed for treating obesity.
- D. With your permission, I'd like you to refer to a support group for individuals who live with severe obesity.
Correct answer: A
Rationale: Increasing physical activity is a key component of managing BMI and overall health.
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