ATI Adult Medical Surgical

ATI Adult Medical Surgical Related

Review ATI Adult Medical Surgical related questions and content

Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement?

  • A. Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath.
  • B. Administer the aspirin with at least two ounces of water or juice.
  • C. Notify the healthcare provider if the child complains of ringing in the ears.
  • D. Advise the parents to question the child about seeing yellow halos around objects.
Correct Answer: C

Rationale: The correct answer is C: Notify the healthcare provider if the child complains of ringing in the ears. This is important because ringing in the ears can be a sign of salicylate toxicity, a potential side effect of aspirin use in children with rheumatic fever. It is crucial to monitor for this symptom to prevent serious complications.

A: Instructing the parents to hold the aspirin until the child has a tepid sponge bath is not the most important intervention. Managing salicylate toxicity takes precedence over comfort measures.

B: Administering the aspirin with at least two ounces of water or juice is a general guideline for medication administration but not the most critical intervention in this scenario.

D: Advising the parents to question the child about seeing yellow halos around objects is not directly related to the potential side effects of aspirin in this case. Monitoring for salicylate toxicity through symptoms like ringing in the ears is more crucial.

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A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective?

  • A. The client's extremities are paralyzed.
  • B. The peripheral nerve stimulator causes twitching.
  • C. The client clenches fist upon command.
  • D. The client's Glasgow Coma Scale score is 14.
Correct Answer: A

Rationale: The correct answer is A because the neuromuscular blocker tubocurarine chloride causes muscle paralysis, leading to the extremities being paralyzed. This indicates that the medication is effectively blocking neuromuscular transmission.
B: Twitching with peripheral nerve stimulation indicates incomplete blockade.
C: Clenching fist upon command indicates preserved muscle strength.
D: Glasgow Coma Scale measures level of consciousness, not neuromuscular blockade.

A client with a history of chronic obstructive pulmonary disease (COPD) presents with increasing shortness of breath. Which assessment finding is most important for the nurse to report to the healthcare provider?

  • A. Barrel-shaped chest.
  • B. Use of accessory muscles to breathe.
  • C. Oxygen saturation of 88%.
  • D. Respiratory rate of 22 breaths per minute.
Correct Answer: C

Rationale: The correct answer is C: Oxygen saturation of 88%. In COPD patients, low oxygen saturation indicates inadequate gas exchange and potential respiratory distress. Oxygen saturation below 90% requires immediate intervention to prevent hypoxemia. A: Barrel-shaped chest is a common finding in COPD due to hyperinflation, but it is not a critical indicator of acute exacerbation. B: Use of accessory muscles suggests increased work of breathing but may not be as urgent as low oxygen saturation. D: Respiratory rate is within normal range, so it is less concerning than the low oxygen saturation.

What is an important teaching point for a patient prescribed dabigatran for atrial fibrillation?

  • A. Take the medication with food to enhance absorption.
  • B. Do not crush or chew the capsules.
  • C. Increase intake of green leafy vegetables.
  • D. Avoid all dairy products.
Correct Answer: B

Rationale: Correct Answer: B

Rationale:
1. Dabigatran is an anticoagulant medication that comes in capsules, which should not be crushed or chewed to maintain its extended-release formulation.
2. Crushing or chewing the capsules can lead to an increased risk of bleeding due to rapid release of the medication.
3. Therefore, advising the patient not to crush or chew the capsules is crucial to ensure the safety and efficacy of dabigatran therapy.

Summary:
A: Taking with food is not necessary for dabigatran absorption.
C: Green leafy vegetables are high in vitamin K, which can interfere with anticoagulant therapy.
D: There is no need to avoid all dairy products while taking dabigatran.

What should the nurse include in patient teaching for a patient prescribed ceftriaxone for bacterial pneumonia?

  • A. Take the medication as prescribed.
  • B. Expect urine color changes.
  • C. Complete the full course of the antibiotic.
  • D. Avoid dairy products during treatment.
Correct Answer: C

Rationale: Rationale:
Ceftriaxone is an antibiotic used for bacterial pneumonia. Completing the full course is essential to completely eradicate the infection and prevent antibiotic resistance. Taking medication as prescribed is a general principle, but not specific to this medication. Urine color changes are not associated with ceftriaxone. Dairy products do not interact with ceftriaxone.

A patient with chronic pain is prescribed a fentanyl patch. What is the most important instruction for the nurse to provide?

  • A. Apply the patch to a different site each time.
  • B. Change the patch every 72 hours.
  • C. Avoid using additional heating pads over the patch.
  • D. Remove the patch before showering.
Correct Answer: B

Rationale: The correct answer is B: Change the patch every 72 hours. Fentanyl patches are typically designed to be worn for 72 hours before being replaced to maintain consistent pain relief. Changing the patch on time helps prevent withdrawal symptoms and ensures the effectiveness of the medication.

A: Applying the patch to a different site each time is important to prevent skin irritation but is not the most crucial instruction.
C: Avoiding heating pads over the patch is important to prevent overheating and excessive absorption of the medication, but changing the patch timely is more critical.
D: Removing the patch before showering is not necessary as fentanyl patches are designed to be water-resistant.

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