ATI Adult Medical Surgical

ATI Adult Medical Surgical Related

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When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client's vital signs are within normal limits. He reports feeling 'out of breath' but denies any other complaints. What action should the nurse take at this time?

  • A. Administer a PRN prescription for diphenhydramine (Benadryl).
  • B. Start the normal saline attached to the Y-tubing at the same rate.
  • C. Decrease the intravenous flow rate of the PRBC transfusion.
  • D. Ask the respiratory therapist to administer PRN albuterol (Ventolin).
Correct Answer: C

Rationale: The correct action for the nurse to take in this situation is to decrease the intravenous flow rate of the PRBC transfusion. The client is showing early signs of a transfusion reaction, as evidenced by feeling 'out of breath'. By decreasing the flow rate of the transfusion, the nurse can slow down the rate at which the remaining blood is infused, potentially preventing a more severe reaction. Administering diphenhydramine or albuterol would not address the underlying issue of a potential transfusion reaction. Starting normal saline at the same rate may exacerbate the client's symptoms and is not indicated in this scenario.

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A patient with epilepsy is prescribed phenytoin. What is the primary side effect the nurse should monitor for?

  • A. Hypotension
  • B. Gingival hyperplasia
  • C. Bradycardia
  • D. Hyperkalemia
Correct Answer: B

Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival overgrowth as a side effect. This is due to its effect on fibroblasts in the gums, leading to increased connective tissue production. Hypotension (A), bradycardia (C), and hyperkalemia (D) are not common side effects of phenytoin. Monitoring for gingival hyperplasia is crucial to prevent complications such as difficulty in eating, speaking, and maintaining oral hygiene.

A patient with chronic kidney disease (CKD) is prescribed erythropoietin. What is the primary action of this medication?

  • A. Stimulate white blood cell production
  • B. Increase platelet count
  • C. Promote red blood cell production
  • D. Enhance clotting factor production
Correct Answer: C

Rationale: The correct answer is C: Promote red blood cell production. Erythropoietin is a hormone that stimulates the production of red blood cells in the bone marrow. This is crucial for patients with CKD who often develop anemia due to decreased erythropoietin production.

A: Stimulating white blood cell production is the function of other medications, such as colony-stimulating factors, not erythropoietin.
B: Erythropoietin does not have an effect on platelet count.
D: Enhancing clotting factor production is not the primary action of erythropoietin.

An outcome for treatment of peripheral vascular disease is, 'The client will have decreased venous congestion.' What client behavior would indicate to the nurse that this outcome has been met?

  • A. Avoids prolonged sitting or standing.
  • B. Avoids trauma and irritation to skin.
  • C. Wears protective shoes.
  • D. Quits smoking.
Correct Answer: A

Rationale: The correct answer is A because avoiding prolonged sitting or standing helps improve venous return by preventing blood from pooling in the legs, reducing venous congestion. This behavior promotes circulation and decreases the risk of complications. Choices B, C, and D do not directly address venous congestion or circulation improvement, making them incorrect options. Avoiding trauma and irritation to the skin (B) is important for skin integrity but not specifically for venous congestion. Wearing protective shoes (C) is related to preventing foot injuries but does not directly impact venous congestion. Quitting smoking (D) is beneficial for overall health but does not directly target venous congestion.

When should the charge nurse intervene based on the observed behavior?

  • A. Two staff members are overheard talking about a cure for AIDS outside a client's room.
  • B. A hospital transporter is reading a client's history and physical while waiting for an elevator.
  • C. A UAP tells a client, 'It's hard to quit drinking but Alcoholics Anonymous helped me.'
  • D. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge.
Correct Answer: B

Rationale: The correct answer is B because it violates patient confidentiality. Reading a client's history and physical in a public area breaches the client's privacy rights. The other choices do not directly compromise patient confidentiality. A involves discussing a cure for AIDS, which is not a breach of confidentiality. C involves sharing personal experiences with the client, and D involves discussing a client's history of drug abuse in a visitor's lounge, which may not be overheard by the client or staff directly involved in the client's care.

What is the primary action of amlodipine when prescribed to a patient with hypertension?

  • A. Increase heart rate
  • B. Reduce blood pressure
  • C. Lower cholesterol levels
  • D. Decrease blood sugar levels
Correct Answer: B

Rationale: The primary action of amlodipine is to reduce blood pressure by relaxing and dilating blood vessels, leading to improved blood flow and lower blood pressure. This is achieved by blocking calcium channels in the blood vessels. Increasing heart rate (A), lowering cholesterol levels (C), and decreasing blood sugar levels (D) are not the primary actions of amlodipine and are not directly related to its mechanism of action in treating hypertension.

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