Question

A nurse is caring for an older adult client who has a WBC count of 2,000/mm³ after three rounds of chemotherapy. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Serve cooked fruit with meals.

Rationale :

✳️ The client has a WBC count of 2,000/mm³, indicating neutropenia, a condition that significantly increases infection risk.

✳️ Serving cooked fruit eliminates pathogens that could be present on raw fruit, making it a safer option for immunocompromised patients.

✳️ The other options—humidifying the room, cleaning dentures in a denture cup, and changing flower vase water—do not adequately address neutropenic precautions or may pose infection risks.

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Answer 2

Correct Answers

Apply ice to the scrotum and penis. [ Anticipated ]
Administer an antispasmodic medication. [ Anticipated ]
Place the client in the sitting position while in bed. [ Contraindicated ]
Teach the client how to use a leg bag. [ Non Essential ]

Rationale :

🔥Apply ice to the scrotum and penis

🍃 Applying ice packs to the scrotum and penis is a common and effective intervention in the immediate postoperative period.

🍃 It helps reduce swelling, bruising, and discomfort by promoting vasoconstriction and decreasing local inflammation.

🍃 Ice should be used intermittently and wrapped properly to avoid skin injury.

🍃 This intervention is standard and anticipated in the postoperative care plan.

🔥 Administer an antispasmodic medication

✍️ After a radical prostatectomy, bladder spasms are a common complication due to catheter irritation or surgical manipulation.

✍️ Antispasmodic medications, such as oxybutynin or belladonna-opium suppositories, are frequently prescribed to relieve this painful involuntary muscle contraction.

✍️ Administering this medication improves comfort and bladder control, making it a routine and expected postoperative measure.

🔥Place the client in the sitting position while in bed

⪼ Placing the client in a sitting upright position exerts direct pressure on the perineum and surgical site, increasing the risk of edema, bleeding, and pain.

⪼ The client should instead be kept in a reclining or supine position with scrotal support to minimize pressure and promote healing.

⪼ This is why sitting upright immediately after surgery is contraindicated.

🔥Teach the client how to use a leg bag

◈ Teaching about a leg drainage bag is important, but it is not essential in the immediate postoperative phase when the priority is monitoring for complications and managing pain.

◈ Instruction about leg bag use can be provided once the client is stable and preparing for discharge.

◈ At this stage, it’s considered nonessential and does not affect the client’s current safety or recovery.

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Answer 3

Correct Answers:

WBC count
Platelet count
Bleeding episodes
Oral health

Rationale :

WBC count

✍️ The white blood cell (WBC) count is a direct indicator of bone marrow recovery, especially after leukemia treatment.

✍️ A rising WBC count suggests that the transplanted bone marrow is producing healthy leukocytes, which is a positive sign of engraftment and immune system recovery.

✍️ Leukemia directly affects WBC production, so this is a critical marker of treatment success.

Platelet count

🍃 Platelets are produced in the bone marrow, and a normalized or improving platelet count reflects effective megakaryocyte production from the transplanted marrow.

🍃 An increase in platelet count indicates better clotting ability and lower risk of bleeding, which is a key measure of bone marrow function post-transplant.

Bleeding episodes

⪢ Fewer or no bleeding episodes after transplantation indicate that the client’s platelet levels and function are improving, reducing hemorrhagic complications.

⪢ This is a clinical sign, not just a lab result, showing that the new marrow is producing functioning platelets capable of maintaining hemostasis.

Oral health

◈ Good oral mucosa condition (e.g., absence of ulcers, dryness, or inflammation) indicates improvement in neutrophil count and mucosal healing, both of which are affected by bone marrow suppression and chemotherapy.

◈ As mucositis resolves, it signals a recovery in the mucous membrane’s immune defense, often linked to improved WBC function and overall immune reconstitution.

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Answer 4

Correct Answers:

"After a couple of years, I will be able to stop taking the Tacrolimus!'

Rationale :

⪼ Immunosuppressive therapy, such as Tacrolimus, must be taken lifelong after a transplant to prevent organ rejection.

⪼ Stopping the medication increases the risk of acute or chronic rejection.

⪼ All other statements reflect correct understanding of transplant drug therapy and the associated risks.

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Answer 5

Correct Answers:

0.5

Rationale :

✔️ Calculation:

✍️Use formula;

↪Tablets = Desired dose ÷ Available dose

▧ Ordered dose: 125 mcg

▧ Available dose: 0.25 mg = 250 mcg

👉125 mcg ÷ 250 mcg

👍= 0.5 tablets

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Answer 6

Correct Answers:

125

Rationale :

✍️Use the formula:

▶mL/hr = Total volume (mL) ÷ Time (hr)

➡️Total volume = 1000 mL

➡️Time = 8 hours

✍️mL/hr = 1000 mL ÷ 8 hours

👍=125 mL/hr

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Answer 7

Correct Answers:

An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of <2 seconds

Rationale :

✳️ This client is experiencing a life-threatening injury: a sucking chest wound, which can lead to a tension pneumothorax and rapid deterioration.

✳️ Though breathing fast (38/min), the client is unconscious, indicating impaired oxygenation or perfusion.

✳️ In triage, the highest priority goes to those who are unstable but salvageable—this client requires immediate airway management to survive.

✳️ The client in option D has no respirations and failed airway attempts, suggesting they're non-salvageable, placing them in the expectant category.

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Answer 8

Correct Answers:

Assess further for a cause of the decreased circulation,

Rationale :

🍃 The absence of pedal and posterior tibial pulses with leg swelling suggests vascular compromise, possibly from compartment syndrome or major vascular injury.

🍃 Before initiating fluids or continuing the trauma survey, the nurse must identify the cause of impaired circulation, as limb salvage depends on rapid recognition and intervention.

🍃 Immediate assessment may prompt surgical consultation or compartment pressure measurement.

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Answer 9

Correct Answers:

Assist with intubation of the patient.

Rationale :

⪢ The patient is unconscious and has ingested a CNS depressant (lorazepam), increasing the risk of loss of airway reflexes and aspiration.

⪢ Airway protection via intubation is the priority before any gastric interventions like charcoal or lavage.

⪢ Intubation ensures that treatment does not lead to aspiration pneumonia or further complications.

⪢ Airway always comes first in unconscious overdose patients, per ACLS and emergency protocols.

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Answer 10

Correct Answers:

Attempt to remove the patient's stings.

Rationale :

◈ The first action in treating bee stings is to remove the stingers to prevent further venom release.

◈ Each stinger can continue to release venom for several minutes, so immediate removal reduces severity of the allergic reaction.

◈ Ice, antihistamines, and calamine lotion are supportive but should follow sting removal to address the source.

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RN ATI Advanced Medsurgical Exam 4

No.

1 :
A nurse is caring for an older adult client who has a WBC count of 2,000/mm³ after three rounds of chemotherapy. Which of the following actions should the nurse take?

2 :
The nurse is caring for a client who has had an open radical prostatectomy.

Correct Answers

3 :
The nurse is caring for a client who has cancer and is undergoing chemotherapy.

Answer Options

4 :
The nurse teaches patients about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

6 :
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number.). Use a leading zero if it applies. Do not use a trailing zero)

7 :
A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

8 :
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

9 :
Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

10 :
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

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Options	Anticipated	Non Essential	Contraindicated
Apply ice to the scrotum and penis.
Administer an antispasmodic medication.
Place the client in the sitting position while in bed.
Teach the client how to use a leg bag.

RN ATI Advanced Medsurgical Exam 4

No.

1 : A nurse is caring for an older adult client who has a WBC count of 2,000/mm³ after three rounds of chemotherapy. Which of the following actions should the nurse take?

2 : The nurse is caring for a client who has had an open radical prostatectomy.

Correct Answers

3 : The nurse is caring for a client who has cancer and is undergoing chemotherapy.

Answer Options

4 : The nurse teaches patients about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

6 : A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number.). Use a leading zero if it applies. Do not use a trailing zero)

7 : A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

8 : During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

9 : Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

10 : The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

1 :
A nurse is caring for an older adult client who has a WBC count of 2,000/mm³ after three rounds of chemotherapy. Which of the following actions should the nurse take?

2 :
The nurse is caring for a client who has had an open radical prostatectomy.

3 :
The nurse is caring for a client who has cancer and is undergoing chemotherapy.

4 :
The nurse teaches patients about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

6 :
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number.). Use a leading zero if it applies. Do not use a trailing zero)

7 :
A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

8 :
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

9 :
Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

10 :
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?