ATI B EXAM.LATEST VERIFIED QUESTIONS AND ANSWERS.A nurse is providing teaching to a client who has a severe form of
stage Il Lyme disease. Which of the
... [Show More] following statements made by the
client reflects an understanding of the teaching?
"I will need to take antibiotics for 1 year." – INCORRECT
o A client who has severe stage I Lyme disease will be
prescribed a 30-day course of antibiotics. The nurse should
emphasize to the client that, like with other types of
infection, the full course of antibiotics should be completed.
"My partner will need to take an antiviral medication." –
INCORRECT
o Lyme disease is a vector-borne illness that is treated with
antibiotics. Other vector-borne illnesses, such as West Nile
Virus, are treated with antiviral medications. Lyme disease
is not transmitted to others via human contact.
"My joints ache because I have Lyme disease." – CORRECT
o Lyme disease is a vector-borne illness transmitted by the
deer tick. The disease course occurs in three stages
beginning with joint and muscle pain in stage I. If left
untreated, these symptoms continue throughout stage I
and, by stage Ill, become chronic. Other chronic
complications include memory problems and fatigue
"I bruise easily because I have Lyme disease. – INCORRECT
o Lyme disease is an infectious disease that affects the body
systemically, involving the neurologic, musculoskeletal, and
cardiac systems. Cardiac manifestations include carditis and
dysrhythmias. However, a client who has stage Il Lyme
disease does not typically experience bruising.
A nurse is caring for a client who is 4 hr postoperative following an
open reduction internal fixation of the right ankle. Which of the
following assessment findings should the nurse report to the provider?
Extremity cool upon palpation – CORRECT
o The nurse should report indicators of reduced circulation,
such as pallor, cool temperature, or paresthesia of the
client's extremity. These findings can indicate that the client
is at risk for developing acute compartment syndrome.
Serosanguineous drainage on the dressing – INCORRECT
o Serosanguineous, or blood-tinged, drainage on the dressing
is an expected finding following surgery. Serosanguineous
drainage is present the first few days following surgery as
the wound heals.
Capillary refill of 2 seconds – INCORRECT
o A capillary refill of 2 seconds is within the expected
reference range and indicates the client has adequate
arterial blood flow. A delay in capillary refill can indicate an
earl manifestation of acute compartment syndrome.
Client report of discomfort when moving toes – INCORRECT
o A report of discomfort when moving toes is an expected
finding following surgery. However, a report of increased
pain at the surgical site when moving can indicate an early
manifestation of acute compartment syndrome.
A nurse is assessing a client while suctioning the client's tracheostomy
tube. Which of the following findings should indicate to the nurse the
client is experiencing hypoxia?
The client starts to cough. – INCORRECT
o The nurse should expect the client to cough during
suctioning of a tracheostomy due to bronchial stimulation.
The client's heart rate increases. – CORRECT
o Hypoxia related to suctioning can cause the client's heart
rate to increase. If this occurs, the nurse should discontinue
the suctioning and manually oxygenate the client with
100% oxygen. The nurse should instruct the client to take
three or four deep breaths prior to suctioning to reduce the
risk for hypoxia.
The client is diaphoretic. – INCORRECT
o Diaphoresis is not associated with suction-induced hypoxia.
However, long-term hypoxia can lead to diaphoresis.
The client's blood pressure decreases. – INCORRECT
o A clients blood pressure can increase initially with hypoxia.
If this occurs, the nurse should stop suctioning and
manually oxygenate the client. Long-term hypoxia can lead
to a decrease in blood pressure and shock
A nurse is caring for a client who is 8 hr postoperative following a total
hip arthroplasty. The client is unable to void on the bedpan. Which of
the following actions should the nurse take first?
Document the client's intake and output. – INCORRECT
o The nurse should document the client's intake and output to
ensure adequate fluid balance. However, there is another
action that the nurse should take first. [Show Less]