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ATI Adult Medical Surgical
1. The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?
- A. Pain during coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct answer: B
Rationale: Clients with myasthenia gravis commonly experience muscle weakness, including in the muscles used for coughing. This diminished cough effort can lead to ineffective airway clearance, increasing the risk of respiratory complications. Therefore, the most likely cause for the nursing diagnosis 'High risk for ineffective airway clearance' in a client with myasthenia gravis is the diminished cough effort due to muscle weakness.
2. Which problem in a client requires the most immediate intervention by the nurse?
- A. Finger paresthesias related to carpal tunnel syndrome.
- B. Increasing sharp pain related to compartment syndrome.
- C. Increasing burning pain related to a Morton's neuroma.
- D. Increasing sharp pain related to plantar fasciitis.
Correct answer: B
Rationale: The correct answer is B: Increasing sharp pain related to compartment syndrome. Compartment syndrome is a serious condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. Immediate intervention is crucial to prevent permanent damage to muscles and nerves, including tissue necrosis and nerve injury. Choices A, C, and D do not present the same level of urgency as compartment syndrome, making them less critical for immediate intervention. Carpal tunnel syndrome, Morton's neuroma, and plantar fasciitis may cause discomfort and functional limitations but are not typically considered emergencies requiring urgent intervention like compartment syndrome.
3. A patient with diabetes insipidus is prescribed desmopressin. What is the primary purpose of this medication?
- A. Increase urine output
- B. Reduce blood sugar levels
- C. Decrease urine output
- D. Lower blood pressure
Correct answer: C
Rationale: Desmopressin is prescribed to decrease urine output in patients with diabetes insipidus. It works by increasing water reabsorption in the kidneys, helping to control fluid balance in the body.
4. A healthcare professional is preparing to administer digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablets. How many tablets should the healthcare professional administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 1
- B. 2
- C. 3
- D. 4
Correct answer: B
Rationale: To achieve the prescribed dose of 0.25 mg, the healthcare professional should administer 2 tablets of 0.125 mg each, totaling 0.25 mg.
5. A client with a history of hypertension is prescribed hydrochlorothiazide. Which instruction should the nurse include in the client's teaching?
- A. Take this medication in the morning.
- B. Avoid foods high in potassium.
- C. Monitor your blood pressure regularly.
- D. Decrease your intake of high-sodium foods.
Correct answer: C
Rationale: Regular monitoring of blood pressure is crucial for individuals with hypertension to assess the effectiveness of the prescribed medication and to ensure blood pressure is within the target range. This helps in managing hypertension and preventing complications associated with high blood pressure. Choices A, B, and D are incorrect because while taking the medication in the morning may be recommended for some drugs, it is not the key instruction for hydrochlorothiazide. Avoiding foods high in potassium and decreasing high-sodium foods are important dietary considerations for certain conditions, but they are not the immediate focus when starting hydrochlorothiazide.
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