2024 ATI RN Adult Medical Surgical 2025 with NGN
Updated 2024 Exam 3 New Latest Version with All
Questions and 100% Correct Answers
Question 1:
A 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.
Show correct answer and explanation
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.
Question 4:
A nurse is providing discharge teaching for a client who has osteomyelitis in the
left leg. Which of the following findings should the nurse identify as requiring a
referral?
A. The client has a WBC count of 20,000/mm3.
B. The client has a prescription for long-term IV antibiotic therapy.
C. The client has a prescription for furosemide.
D. The client has type 2 diabetes mellitus and a HbA1c of 6%.
Show correct answer and explanation
, Explanation
A WBC count of 20,000/mm3 indicates an active infection and inflammation,
which may require further evaluation and treatment by the health care
provider. The nurse should notify the provider and refer the client for follow-
up care if this finding persists or worsens after discharge. Long-term IV
antibiotic therapy is a common treatment for osteomyelitis and does not
require a referral unless there are complications or adverse effects.
Furosemide is a diuretic that may be prescribed for clients who have fluid
retention or hypertension, which are not related to osteomyelitis. A HbA1c
of 6% indicates good glycemic control for a client with type 2 diabetes
mellitus, which can help prevent complications and infections.
Question 5:
A nurse is assessing a client who has increased intracranial pressure (ICP). The
nurse should recognize that which of the following is the first sign of deteriorating
neurological status?
A. Pupillary dilation
B. Decorticate posturing
C. Altered level of consciousness
D. Cheyne-Stokes respirations
Show correct answer and
explanation Explanation
Altered level of consciousness (LOC) is the earliest and most sensitive indicator
of increased ICP, which can result from brain injury, tumor, hemorrhage, infection,
or edema.
The nurse should monitor the client's LOC using the Glasgow Coma Scale
(GCS) and report any changes or deterioration to the provider. Pupillary
dilation, decorticate posturing, and Cheyne-Stokes respirations are later
signs of increased ICP that indicate brainstem compression and herniation,
which are life-threatening emergencies.
Question 6:
Updated 2024 Exam 3 New Latest Version with All
Questions and 100% Correct Answers
Question 1:
A 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.
Show correct answer and explanation
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.
Question 4:
A nurse is providing discharge teaching for a client who has osteomyelitis in the
left leg. Which of the following findings should the nurse identify as requiring a
referral?
A. The client has a WBC count of 20,000/mm3.
B. The client has a prescription for long-term IV antibiotic therapy.
C. The client has a prescription for furosemide.
D. The client has type 2 diabetes mellitus and a HbA1c of 6%.
Show correct answer and explanation
, Explanation
A WBC count of 20,000/mm3 indicates an active infection and inflammation,
which may require further evaluation and treatment by the health care
provider. The nurse should notify the provider and refer the client for follow-
up care if this finding persists or worsens after discharge. Long-term IV
antibiotic therapy is a common treatment for osteomyelitis and does not
require a referral unless there are complications or adverse effects.
Furosemide is a diuretic that may be prescribed for clients who have fluid
retention or hypertension, which are not related to osteomyelitis. A HbA1c
of 6% indicates good glycemic control for a client with type 2 diabetes
mellitus, which can help prevent complications and infections.
Question 5:
A nurse is assessing a client who has increased intracranial pressure (ICP). The
nurse should recognize that which of the following is the first sign of deteriorating
neurological status?
A. Pupillary dilation
B. Decorticate posturing
C. Altered level of consciousness
D. Cheyne-Stokes respirations
Show correct answer and
explanation Explanation
Altered level of consciousness (LOC) is the earliest and most sensitive indicator
of increased ICP, which can result from brain injury, tumor, hemorrhage, infection,
or edema.
The nurse should monitor the client's LOC using the Glasgow Coma Scale
(GCS) and report any changes or deterioration to the provider. Pupillary
dilation, decorticate posturing, and Cheyne-Stokes respirations are later
signs of increased ICP that indicate brainstem compression and herniation,
which are life-threatening emergencies.
Question 6:
