2024 ATI RN Adult Medical Surgical 2019 with NGN
Updated 2024 Exam 3 New Latest Version with All
Questions and 100% Correct Answers
Question 1:
A
... [Show More] nurse is caring for a client who has tuberculosis and is taking rifampin. The
client reports that her saliva has turned red-orange in color. Which of the
following responses should the nurse make?
A. "Your provider will prescribe a different medication regimen."
B. "This is an expected adverse effect of this medication."
C. "This finding may indicate possible medication toxicity."
D. "You will need to increase your fluid intake to resolve this problem."
Show correct answer and explanation
Explanation
Rifampin is an antitubercular drug that can cause red-orange discoloration of
body fluids, such as saliva, urine, sweat, and tears. This is a harmless and
expected adverse effect of this medication and does not indicate toxicity or a
need for a change in therapy.
The nurse should inform the client about this effect and reassure them that it will
subside after the completion of the treatment. The nurse should also advise the
client to avoid wearing contact lenses as they may become stained by the drug.
Question 2:
A nurse is teaching the family of a client who has Alzheimer's disease about
caring for the client at home. Which of the following instructions should the
nurse include?
A. Cover electrical outlets in the client's home with tape.
B. Hang a monthly calendar in the client's bedroom.
C. Keep the client's bedroom dark at night.
D. Place a large-face clock in the client's bedroom.
Show correct answer and explanation
Explanation
A monthly calendar can help the client with Alzheimer's disease to orient to time
and date and reduce confusion and anxiety. The nurse should encourage the
family to use simple and clear reminders and cues to assist the client with daily
activities and routines.
Covering electrical outlets with tape is not necessary and may pose a fire hazard.
Keeping the client's bedroom dark at night may increase the risk of falls and
injuries. A large-face clock may be helpful, but not as much as a calendar.
Question 3:
A nurse is planning care for a client who has Clostridium difficile
gastroenteritis. Which of the following is an appropriate nursing action?
A. Place the client in a protective environment.
B. Clean surfaces with chlorhexidine.
C. Wash hands with alcohol-based hand rub.
D. Obtain a stool specimen with gloves.
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Explanation
Clostridium difficile is a spore-forming bacterium that causes severe diarrhea
and colitis in clients who have been exposed to antibiotics or have compromised
immune systems. The nurse should obtain a stool specimen with gloves to
confirm the diagnosis and initiate appropriate treatment. The nurse should also
use contact precautions when caring for the client, such as wearing gloves and
gown, and washing hands with soap and water before and after contact.
Alcohol-based hand rubs are not effective against spores and should not be
used for hand hygiene in this case. Chlorhexidine is also not sporicidal and
should not be used for environmental cleaning. A protective environment is
indicated for clients who are at risk of infection from others, not for clients who
are infectious to others. [Show Less]