Ati capstone week 9 exam
Total Questions : 46
Showing 25 questions, Sign in for moreA nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate?
Explanation
Rationale:
A. A low sodium diet is not appropriate for a client with SIADH and hyponatremia, as it can exacerbate the low sodium levels. Increasing sodium intake might be more appropriate depending on the clinical situation.
B. Restricting fluid intake is a standard treatment for SIADH to prevent further dilution of sodium in the blood, which is critical in managing hyponatremia.
C. Desmopressin acetate is used to treat conditions with insufficient antidiuretic hormone, such as diabetes insipidus, and is not appropriate for SIADH.
D. An IV of 0.45% sodium chloride is hypotonic and could worsen hyponatremia in SIADH. Hypertonic saline would be more appropriate if IV treatment were necessary
A nurse is reviewing a client's laboratory results and sees that their hemoglobin A1C is 9%. Which of the following statements from the nurse is appropriate?
Explanation
Rationale:
A. Hemoglobin A1C reflects average blood glucose levels over the past 2 to 3 months, not just after meals, so this statement is not fully accurate.
B. A high A1C indicates chronically high blood glucose levels, not low blood sugar levels, so this statement would be misleading.
C. An A1C of 9% indicates that the client's average blood sugar has been high over the past few months, which increases the risk of diabetes-related complications.
D. While a high A1C may suggest variability in blood glucose levels, the more accurate statement is that the average blood glucose is high, which is what the A1C primarily reflects
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?
Explanation
Rationale:
A. While administering oxygen can help with overall oxygenation, it does not specifically address the issue of thick, tenacious secretions.
B. A low-salt diet might be indicated for other health concerns but does not directly impact bronchial secretions.
C. Semi-Fowler's position can help with lung expansion and ease of breathing but does not directly assist with loosening secretions.
D. Drinking 2 to 3 liters of water daily helps to thin bronchial secretions, making it easier for the client to expectorate (cough up) the mucus, which is particularly important in managing COPD.
A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?
Explanation
Rationale:
A. Examining feet daily is important for preventing foot complications, such as ulcers, in diabetics but is not directly related to preventing retinopathy and nephropathy.
B. Wearing compression stockings is not specifically recommended for preventing retinopathy or nephropathy in diabetes.
C. Maintaining stable blood glucose levels is crucial for preventing or slowing the progression of diabetic complications such as retinopathy and nephropathy. Good glycemic control minimizes the damage to blood vessels in the eyes and kidneys.
D. While regular eye exams are important for detecting retinopathy early, maintaining stable blood glucose levels is key to preventing the development of complications in the first place.
A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?
Explanation
Rationale:
A. Epoetin alfa is used to stimulate the production of red blood cells, so an increase in hematocrit levels would indicate a therapeutic effect. This is particularly important in clients with chronic renal disease, who often suffer from anemia due to decreased erythropoietin production by the kidneys.
B. The erythrocyte sedimentation rate (ESR) is a nonspecific measure of inflammation and is not used to monitor the effectiveness of epoetin alfa therapy.
C. The leukocyte count measures white blood cells and is not affected by or used to assess the effectiveness of epoetin alfa.
D. The platelet count measures platelets in the blood and is not related to the therapeutic effects of epoetin alfa, which targets red blood cell production.
A nurse is caring for a client with a pheochromocytoma. Which assessment finding will the nurse expect for this client?
Explanation
Rationale:
A. A decreased pulse is not typically associated with pheochromocytoma. This condition is characterized by the excessive release of catecholamines, which usually leads to an increased heart rate.
B. Pheochromocytoma is a tumor of the adrenal medulla that causes excessive secretion of catecholamines, leading to episodic or sustained hypertension. Elevated blood pressure is a hallmark symptom of this condition.
C. Cold intolerance is more commonly associated with hypothyroidism and is not a typical finding in pheochromocytoma.
D. Decreased respiratory rate is not characteristic of pheochromocytoma; instead, clients may experience symptoms such as palpitations, sweating, and headaches due to the elevated catecholamine levels.
A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity?
Explanation
Rationale:
A. Ondansetron is an antiemetic that does not typically cause nephrotoxicity and is generally safe for use in clients with chronic kidney disease.
B. Diphenhydramine is an antihistamine that does not have nephrotoxic effects and is commonly used for allergy symptoms or as a sleep aid.
C. Gentamicin is an aminoglycoside antibiotic that is known to be nephrotoxic, especially in clients with pre-existing kidney disease. It requires careful monitoring of kidney function and dosing adjustments to prevent kidney damage.
D. Omeprazole is a proton pump inhibitor used to treat gastroesophageal reflux disease (GERD) and does not typically cause nephrotoxicity, although long-term use has been associated with an increased risk of chronic kidney disease.
A nurse is preparing a client for a kidney biopsy. Which of the following client conditions should the nurse identify as a contraindication for this diagnostic test?
Explanation
Rationale:
A. Flank pain alone is not a contraindication for a kidney biopsy, although it may be a symptom that necessitates the biopsy to determine the cause of kidney issues.
B. An elevated creatinine level indicates impaired kidney function but is not a contraindication for a kidney biopsy; in fact, it may be a reason to perform the biopsy.
C. A coagulation disorder is a contraindication for a kidney biopsy because it increases the risk of bleeding during and after the procedure. It is crucial to ensure that coagulation parameters are within a safe range before performing this invasive test.
D. Urinary retention does not contraindicate a kidney biopsy, although it may need to be addressed separately.
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
Explanation
Rationale:
A. It is essential to keep the drainage system below the level of the client's chest to prevent backflow of fluid into the pleural space, which could lead to complications such as a pneumothorax.
B. Clamping the chest tube is generally not recommended during transport because it can lead to a buildup of pressure in the pleural space, increasing the risk of a tension pneumothorax.
C. Disconnecting the chest tube from the drainage system is not advisable, as this could lead to air entering the pleural space, causing a pneumothorax.
D. Emptying the collection chamber is not necessary prior to transport, and it could lead to inaccurate measurement of fluid output. The focus should be on ensuring that the system remains intact and below chest level during transport.
A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?
Explanation
Rationale:
A. Exophthalmos is typically associated with hyperthyroidism, particularly in Graves' disease, and is not a characteristic finding in hypothyroidism.
B. Weight gain is a common symptom of hypothyroidism due to the slowed metabolism caused by reduced thyroid hormone levels. Clients often report unexplained weight gain despite maintaining a normal diet and activity level.
C. Diaphoresis, or excessive sweating, is more commonly associated with hyperthyroidism, where increased metabolism leads to heat intolerance and sweating.
D. Palpitations are also more commonly associated with hyperthyroidism, where an increased heart rate and heightened sensitivity to adrenaline are common. In hypothyroidism, bradycardia or a slowed heart rate may be observed instead.
A client is receiving desmopressin intranasally. Which assessment parameters would the nurse monitor to determine the effectiveness of this medication?
Explanation
Rationale:
A. Desmopressin is a synthetic analog of antidiuretic hormone (ADH) and is used to reduce urine output in conditions like diabetes insipidus. Monitoring urine output is the primary way to assess the effectiveness of this medication. A decrease in urine volume indicates the medication is working effectively.
B. Pupillary response is not relevant in assessing the effectiveness of desmopressin.
C. Temperature monitoring is important in general patient care but does not directly relate to the effectiveness of desmopressin.
D. Apical heart rate is important to monitor in many scenarios but is not a direct indicator of desmopressin's effectiveness.
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?
Explanation
Rationale:
A. Adjusting the rate of the bladder irrigation might be necessary, but it is not the first action to take when there is no drainage.
B. Ambulating the client can help promote bladder function, but it is not the immediate priority when assessing catheter function.
C. Notifying the provider is important if the issue cannot be resolved, but the nurse should first attempt to resolve common, simple issues like a kinked tube.
D. Checking the tubing for kinks is the most immediate and logical first action to take. Kinks in the tubing can obstruct urine flow, and correcting this can often resolve the issue without further intervention.
A nurse is preparing a teaching session about reducing the risk of complications of diabetes mellitus. Which of the following information should the nurse plan to include in the teaching? (Select all that apply.)
Explanation
Rationale:
A. Reducing cholesterol and saturated fat intake is important for managing cardiovascular health, which is crucial for clients with diabetes to prevent complications such as heart disease and stroke.
B. Sustaining hyperglycemia is incorrect; it actually contributes to complications like neuropathy, retinopathy, and nephropathy. The goal is to maintain blood glucose levels within the target range.
C. Maintaining optimal blood pressure is essential in preventing diabetic nephropathy, as high blood pressure can damage the kidneys and worsen diabetic kidney disease.
D. Increasing physical activity helps improve insulin sensitivity, control blood glucose levels, and reduce the risk of complications associated with diabetes.
E. Smoking cessation is critical in reducing the risk of cardiovascular disease, which is higher in clients with diabetes. Smoking can exacerbate the complications of diabetes.
A prenatal client is experiencing calf pain when she walks. Which action is appropriate for the nurse to implement?
Explanation
Rationale:
A. Limiting walking episodes may reduce discomfort but does not address the underlying issue or potential complications.
B. While leg cramps can be common during pregnancy, calf pain could also indicate a more serious condition, such as deep vein thrombosis (DVT), and should not be dismissed as normal without further investigation.
C. Gathering further assessment data is crucial to determine the cause of the calf pain, as it may indicate DVT, a potentially life-threatening condition. The nurse should assess for other symptoms like swelling, redness, or warmth in the leg.
D. Instructing the client to elevate the legs may be appropriate for general discomfort, but without proper assessment, it may not be the correct intervention if DVT is present.
A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)
Explanation
Rationale:
A. A decreased level of consciousness is a common symptom of ARF due to hypoxemia, which reduces oxygen delivery to the brain, leading to confusion, agitation, or lethargy.
B. Hypercarbia, or elevated levels of carbon dioxide (CO2) in the blood, occurs due to impaired gas exchange in ARF, which leads to respiratory acidosis.
C. Severe dyspnea, or difficulty breathing, is a hallmark symptom of ARF as the lungs fail to maintain adequate oxygenation or ventilation.
D. Nausea is not a typical manifestation of ARF; while it may occur due to other factors, it is not directly associated with respiratory failure.
E. Tachycardia, or an increased heart rate, is often seen in ARF as the body attempts to compensate for hypoxemia by increasing cardiac output to deliver more oxygen to tissues.
A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching?
Explanation
Rationale:
A. During the oliguric phase of acute kidney injury, BUN and creatinine levels typically increase due to reduced kidney function, not decrease.
B. The oliguric phase is characterized by significantly reduced urine output, often defined as less than 400 mL per 24 hours, indicating severe kidney impairment.
C. The GFR does not recover during the oliguric phase; it is significantly decreased, contributing to the accumulation of waste products in the blood.
D. Renal function is not reestablished during the oliguric phase; this occurs in later stages, such as the diuretic or recovery phase.
The nurse assessing a client hospitalized with a diagnosis of hypoparathyroidism notes positive Trousseau's and Chvostek's signs. The nurse determines that these findings most indicate which electrolyte imbalance?
Explanation
Rationale:
A. Hypernatremia, an elevated sodium level, does not cause Trousseau's or Chvostek's signs.
B. Hypermagnesemia, an elevated magnesium level, is not associated with positive Trousseau's and Chvostek's signs.
C. Hypocalcemia, a low calcium level, is commonly associated with positive Trousseau's and Chvostek's signs. Trousseau's sign is a carpopedal spasm induced by inflating a blood pressure cuff, while Chvostek's sign is facial twitching in response to tapping over the facial nerve. Both are indicative of neuromuscular irritability due to low calcium levels.
D. Hypokalemia, a low potassium level, does not cause these specific signs and is associated with different clinical manifestations.
What information would the nurse include when educating a postsurgical client on the proper use of antiembolism stockings? (Select all that apply)
Explanation
Rationale:
A. The nurse should inform the client that if the stockings are too tight, they may impair blood flow rather than prevent it, which could increase the risk of complications such as pressure sores or circulatory issues.
B. While the stockings should be removed periodically, removing them only once daily for 30 minutes may not be sufficient for skin inspection and care. Best practice usually involves removing them more frequently, such as every 8 hours, to check for skin integrity.
C. Proper skin hygiene and regular assessment should be performed each time the stockings are removed to ensure there is no irritation, breakdown, or circulatory impairment.
D. Antiembolism stockings are designed to be worn both in and out of bed to maintain consistent pressure on the legs and reduce the risk of deep vein thrombosis (DVT).
E. Proper measuring of the leg is crucial to ensure that the stockings fit correctly, providing the necessary compression without being too tight or too loose.
A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?
Explanation
Rationale:
A. Fluid intake may need to be monitored, but restricting fluids is not typically advised unless specifically directed by the healthcare provider due to complications like diabetes insipidus.
B. Avoiding deep breathing exercises is not recommended, as these exercises are important for preventing respiratory complications postoperatively.
C. Lying flat for 48 hours after surgery is incorrect; the head of the bed is usually elevated to decrease intracranial pressure and promote healing.
D. Avoiding blowing the nose and bending at the waist is crucial after transsphenoidal hypophysectomy to prevent increased intracranial pressure and avoid disrupting the surgical site, which could lead to complications such as cerebrospinal fluid leakage.
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?
Explanation
Rationale:
A. Bubbling in the water seal chamber with exhalation can be normal as it indicates air is escaping from the pleural space; however, continuous bubbling may indicate an air leak and would need to be assessed.
B. Movement of the trachea toward the unaffected side is a sign of a tension pneumothorax, a life-threatening condition requiring immediate
medical intervention. This tracheal deviation suggests that the pressure in the pleural space is increasing, pushing the mediastinum to the opposite side.
C. Scant serosanguinous drainage on the dressing is expected and not an immediate concern unless it becomes excessive.
D. Crepitus, or subcutaneous emphysema, indicates air leakage into the tissues but is not immediately life-threatening unless it is extensive and worsening rapidly.
A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching?
Explanation
Rationale:
A. Injecting insulin into the abdominal area is appropriate as it is one of the preferred sites for insulin administration due to its consistent absorption.
B. Blood sugar readings should be taken before meals, not after, to determine the need for insulin and to manage blood glucose levels effectively.
C. Insulin does not allow for unrestricted consumption of high-sugar foods like ice cream; instead, a balanced diet is important to maintain stable blood glucose levels.
D. While weight reduction can help manage diabetes, it does not inherently cause hypoglycemia unless the client is taking insulin or other medications that lower blood glucose.
A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?
Explanation
Rationale:
A. Airway patency is the highest priority following a thyroidectomy due to the risk of airway obstruction from swelling or hematoma formation near the surgical site. Compromised airway can lead to respiratory distress and requires immediate attention.
B. While monitoring temperature is important for detecting potential infections, it is not the immediate priority.
C. Pain control is important for comfort and recovery, but it is not life-threatening.
D. Urination should be monitored postoperatively, but it is not as critical as ensuring a patent airway.
A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?
Explanation
Rationale:
A. Discomfort at the puncture site is expected after a thoracentesis and typically managed with analgesics.
B. A decreased temperature is not a common complication of thoracentesis and might indicate other issues, but it is not immediately alarming.
C. An increased heart rate (tachycardia) could be a sign of a pneumothorax, hemorrhage, or other serious complications following thoracentesis. This requires immediate assessment and intervention.
D. Serosanguineous drainage is expected to some extent, but it should be monitored for changes that might indicate a complication such as infection or continued bleeding.
A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?
Explanation
Rationale:
A. Purulent dialysate outflow is a sign of infection, specifically peritonitis, which is a serious complication of peritoneal dialysis that requires immediate medical attention.
B. Blood-tinged dialysate can occur, especially if the client is new to dialysis or has had recent abdominal surgery, but it should be monitored rather than immediately reported unless it is excessive.
C. A feeling of fullness during the dialysate dwelling phase is common and usually resolves as the body adjusts to the procedure.
D. Discomfort during dialysate inflow can occur, particularly with fast inflow rates or high dialysate volumes, but it is not immediately life-threatening.
A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear?
Explanation
Rationale:
A. Popping sounds, also known as crackles, are typically associated with fluid in the alveoli, often seen in conditions like pneumonia or heart failure, not pleurisy.
B. Loud, grating sounds, known as pleural friction rub, are characteristic of pleurisy. This sound is produced by the inflamed pleural surfaces rubbing together during respiration.
C. Snoring sounds, or rhonchi, are usually heard in conditions involving airway obstruction by mucus, such as bronchitis, rather than pleurisy.
D. Squeaky, musical sounds, or wheezing, are associated with airway narrowing, such as in asthma or chronic obstructive pulmonary disease (COPD), and are not typically heard in pleurisy.
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