ATI Medical Surgical Proctored Exam 2019 Quizlet

ATI Medical Surgical Proctored Exam 2019 Quizlet Related

Review ATI Medical Surgical Proctored Exam 2019 Quizlet related questions and content

A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating?

  • A. Administer sargramostim (Leukine, Prokine).
  • B. Infuse PRBC and platelet transfusions.
  • C. Give parenteral prophylactic antibiotics.
  • D. Maintain a protective isolation environment.
Correct Answer: D

Rationale: The correct answer is D: Maintain a protective isolation environment. During bone marrow repopulation after transplantation, the client is at high risk of infection due to compromised immune function. By maintaining a protective isolation environment, the nurse can minimize the risk of exposure to pathogens that could lead to infections. This intervention helps prevent potential complications and supports the client's recovery.

Rationale for other choices:
A: Administering sargramostim may enhance white blood cell production but does not directly address the risk of infection during bone marrow repopulation.
B: Infusing PRBC and platelet transfusions may be necessary for managing anemia and thrombocytopenia but does not address the priority of infection prevention.
C: Giving prophylactic antibiotics may be beneficial in some cases, but maintaining a protective isolation environment is the priority to reduce the risk of infection in this immunocompromised client.

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A client in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?

  • A. Administer oxygen via face mask.
  • B. Notify the operating room team.
  • C. Place the client in Trendelenburg.
  • D. Administer a fluid bolus of 500 ml.
Correct Answer: C

Rationale: The correct answer is C: Place the client in Trendelenburg. This position helps alleviate pressure on the umbilical cord, preventing compression and improving blood flow to the fetus. It is crucial to prioritize this action to prevent fetal distress or compromise. Administering oxygen (A) is important, but not the initial priority. Notifying the operating room team (B) may be necessary but is not the immediate action. Administering a fluid bolus (D) is not indicated in this situation. Placing the client in Trendelenburg is the most appropriate and urgent action to ensure the safety and well-being of the fetus.

When assessing a client reporting severe pain in the right lower quadrant of the abdomen, which sign would most likely indicate appendicitis?

  • A. Rebound tenderness at McBurney's point.
  • B. Positive Murphy's sign.
  • C. Rovsing's sign.
  • D. Cullen's sign.
Correct Answer: A

Rationale: The correct answer is A: Rebound tenderness at McBurney's point. McBurney's point is located in the right lower quadrant and is a classic sign of appendicitis. Rebound tenderness at this point indicates inflammation in the peritoneum, suggesting appendicitis. Choices B, C, and D are not specific to appendicitis. Positive Murphy's sign is related to cholecystitis, Rovsing's sign is seen in acute appendicitis but is not as specific as rebound tenderness at McBurney's point, and Cullen's sign is associated with acute pancreatitis.

The healthcare provider is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention?

  • A. Weigh the child daily.
  • B. Observe the lower extremities for pitting edema.
  • C. Measure the child's abdominal girth weekly.
  • D. Weigh the child's wet diapers.
Correct Answer: A

Rationale: The correct answer is A: Weigh the child daily. Daily weight monitoring is the most accurate way to determine fluid retention in a child with nephrotic syndrome as it provides real-time data on fluid status. Weight gain is a key indicator of fluid retention in these patients. Observing lower extremities for pitting edema (B) is subjective and may not accurately reflect fluid status. Measuring abdominal girth weekly (C) may not provide timely information on fluid retention. Weighing wet diapers (D) does not give a comprehensive picture of total fluid retention and may not be as accurate as daily weight monitoring.

When a client reports being allergic to penicillin, which question should the nurse ask to gather more information?

  • A. Are you allergic to any other medications?
  • B. How often have you taken penicillin in the past?
  • C. Is anyone else in your family allergic to penicillin?
  • D. What happens to you when you take penicillin?
Correct Answer: D

Rationale: Rationale: Option D is the correct answer because it directly addresses the client's experience with penicillin, providing crucial details about the allergic reaction. By asking what happens when the client takes penicillin, the nurse gains specific information to assess the severity and type of allergic reaction. This helps in determining appropriate interventions and alternative medications. Options A, B, and C are incorrect as they do not focus on gathering detailed information about the client's allergic reaction to penicillin. Option A is too broad, option B is not relevant to the current situation, and option C does not directly address the client's individual experience.

The client with newly diagnosed osteoporosis is being taught by the nurse about dietary modifications. Which instruction should the nurse include?

  • A. Increase your intake of high-calcium foods.
  • B. Limit your intake of vitamin D-rich foods.
  • C. Avoid foods high in phosphorus.
  • D. Increase your intake of high-sodium foods.
Correct Answer: A

Rationale: The correct answer is A: Increase your intake of high-calcium foods. Osteoporosis is a condition characterized by low bone density, and calcium is essential for bone health. Increasing calcium intake can help strengthen bones and prevent further bone loss. Foods high in calcium, such as dairy products, leafy green vegetables, and fortified foods, are beneficial for individuals with osteoporosis.

Summary of other choices:
B: Limiting intake of vitamin D-rich foods is not advised, as vitamin D plays a crucial role in calcium absorption and bone health.
C: Avoiding foods high in phosphorus is not necessary, as phosphorus is also important for bone health and overall body function.
D: Increasing intake of high-sodium foods is not recommended, as high sodium intake can lead to calcium loss from the bones, worsening osteoporosis.

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