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ATI MED SURG PROCTORED EXAM RETAKE
(VERIFIED ANSWERS)
Question 1: A nurse is monitoring a client who is undergoing
anticoagulant therapy with heparin. Which of the following findings should nurse identify as a possible indication of hemorrhage?
- Rapid Pulse
- Yellowing of the sclera
- Elevated blood pressure
- Pale-colored stools
CORRECT ANSWER : a. Rapid Pulse
In the event of a moderate to severe hemorrhage, the volume of blood in the circulatory system decreases significantly, resulting in hypotension. Tachycardia is a compensatory mechanism of the heart that serves to combat the hypotension that results from the decreased volume of blood. Tachycardia can be detected by checking the client's pulse.
Question 2: A nurse is caring for a client who is experiencing an
acute ischemic cerebrovascular event due to thrombus in
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cerebral vessel. Which of the following drugs should the nurse expect to administer?
- Alteplase
- Aspirin
- Clopidrogel
- Heparin
CORRECT ANSWER : a. Alteplase
Alteplase is a thrombolytic drug, meaning it can dissolve existing thrombi, whereas anticoagulant/antiplatelet drugs do not. An acute ischemic cerebrovascular event is often caused by the occlusion of a cerebral vessel by a thrombus. Administration of alteplase should be within 3 hr of the original onset of symptoms for the drug to be effective.
Question 3: A nurse is caring for a client who has renal failure
and is receiving epoetin. The nurse should monitor the client for which of the following adverse effects?
- Hypertension
- Muscle pain
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- Edema
- Dry mouth
CORRECT ANSWER : a. Hypertension
Epoetin, an erythropoietic growth factor, can cause hypertension. The nurse should monitor the client's BP before and during therapy and inform the provider if it increases.
Question 4: A nurse is caring for a client who is about to begin
taking aspirin to reduce the risk of a cardiovascular event. The nurse should identify that the drug inhibits platelet aggregation by which of the following mechanisms?
- Activating thromboxane A2
- Blocking adenosine diphosphate receptor agonists
- Suppressing specific clotting factors
- Inhibiting cyclooxygenase action in platelets
CORRECT ANSWER : d. Inhibiting cyclooxygenase action in
platelets
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Salicylates, such as aspirin, work by inhibiting platelet aggregation. They do this by blocking the action of cyclooxygenase on platelets. As a result, activation of thromboxane A2 does not occur.
Question 5: A nurse is administering epoetin intravenously to a
client who has renal failure. Which of the following actions should the nurse take?
- Shake the vial before using.
- Administer via IV bolus over 1 to 3 min.
- Dilute the drug first with D5W.
- Save the used vial for the next dose.
CORRECT ANSWER: b. Administer via IV bolus over 1 to 3
min
Instructions for administering the drug include administering it via IV bolus over 1 to 3 min.
Question 6: A nurse is caring for a client who is taking ferrous
sulfate to treat iron-deficiency anemia and develops iron