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Adult Medical Surgical ATI
1. The client with newly diagnosed hypertension is being taught about lifestyle modifications. Which recommendation should be made?
- A. Increase your intake of saturated fats.
- B. Limit your alcohol intake to two drinks per day.
- C. Engage in at least 150 minutes of moderate exercise per week.
- D. Use table salt liberally to season your food.
Correct answer: C
Rationale: Engaging in at least 150 minutes of moderate exercise per week is a key lifestyle modification recommended for individuals with hypertension. Regular exercise helps manage blood pressure, improve cardiovascular health, and overall well-being. It is important for the client to adopt a healthy lifestyle to control hypertension and reduce the risk of complications.
2. A client's healthcare provider has ordered a 'liver panel' in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select one that doesn't apply.
- A. Alanine aminotransferase (ALT)
- B. C-reactive protein (CRP)
- C. Gamma-glutamyl transferase (GGT)
- D. Aspartate aminotransferase (AST)
Correct answer: B
Rationale: A 'liver panel' is a group of blood tests used to evaluate liver function. The components typically include ALT, GGT, and AST. While C-reactive protein (CRP) is a marker of inflammation and not part of a standard liver panel, it may be ordered for other diagnostic purposes.
3. A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Bowel sounds active in all quadrants.
- B. Blood pressure of 110/70 mm Hg.
- C. Rigid, board-like abdomen.
- D. Heart rate of 90 beats per minute.
Correct answer: C
Rationale: A rigid, board-like abdomen is a sign of peritonitis, a serious complication of peptic ulcer disease that can lead to sepsis and requires immediate intervention. This finding indicates a potential emergency situation that needs urgent medical attention to prevent further complications.
4. The charge nurse observes that a client with a nasogastric tube on low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel (UAP) left the room. What action should the nurse take?
- A. Remove the glass of water and speak to the UAP.
- B. Discuss the incident with the UAP at the end of the day.
- C. Write an incident report and notify the healthcare provider.
- D. Remind the client of the potential for electrolyte imbalance.
Correct answer: A
Rationale: The correct action for the charge nurse to take is to remove the glass of water and speak to the UAP. This ensures immediate correction and education to prevent further issues with the nasogastric tube. Addressing the situation promptly can prevent harm to the client and reinforces the importance of following proper protocols.
5. A client with liver cirrhosis is prescribed lactulose. What is the purpose of this medication?
- A. To lower blood sugar levels
- B. To reduce ammonia levels
- C. To treat liver inflammation
- D. To improve bile flow
Correct answer: B
Rationale: Lactulose is prescribed to reduce ammonia levels in clients with liver cirrhosis. Elevated ammonia levels can lead to hepatic encephalopathy, a serious complication of liver cirrhosis. Lactulose works by acidifying the colon, which in turn traps ammonia in the colon and helps its elimination from the body through stool, thereby reducing the risk of hepatic encephalopathy. Choice A is incorrect because lactulose does not lower blood sugar levels. Choice C is incorrect as lactulose is not used to treat liver inflammation. Choice D is incorrect as lactulose does not improve bile flow.
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