ATI RN Fundamentals Online Practice 2024 EDITION GRADE A+

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? Increase in hematocrit increase in respiratory rate Decrease in heart rate Decrease in capillary refill time Correct Answer: Decrease in heart rate Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. Incorrect Answers: Increase in hematocrit: Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular fluid. With correction of the imbalance, the hematocrit level should decrease. increase in respiratory rate Fluid volume deficit causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range. Decrease in capillary refill time Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range. A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate? "The transfer of your family member is being done because the provider knows what's best." "Would you like it if we discussed the transfer with your family member?" "Why are you so concerned about this transfer?" "I know how you feel. My parent had to be transferred to a long-term care facility." Correct Answer: "Would you like it if we discussed the transfer with your family member?" This response facilitates therapeutic communication and provides general leads while maintaining client confidentiality. Incorrect Answers: "The transfer of your family member is being done because the provider knows what's best." This is a defensive response which can hinder further communication. "Why are you so concerned about this transfer?" Asking a why question can make the recipient defensive which can hinder further communication. "I know how you feel. My parent had to be transferred to a long-term care facility." This is a sympathetic response, which can interfere with a therapeutic relationship. A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurse report to the provider? BUN 21 mg/dL (10 to 20 mg/dL) Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL) Sodium 132 mEq/L (136 to 145 mEq/L) Potassium 5.8 mEq/L (3.5 to 5 mEq/L) Correct Answer: Potassium 5.8 mEq/L (3.5 to 5 mEq/L) When using the urgent versus nonurgent approach to client care, the nurse should determine that this potassium level is above the expected reference range and should be reported to the provider. Potassium affects the contractility of the heart and this client would be at risk for developing dysrhythmias. Incorrect answers: BUN 21 mg/dL (10 to 20 mg/dL) This BUN level is slightly above the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a priority for the nurse to report to the provider. Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL) This creatinine level is slightly above the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a a priority for the nurse to report to the provider. Sodium 132 mEq/L (136 to 145 mEq/L) This sodium level is slightly below the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a priority for the nurse to report to the provider. A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? "Drink a cup of hot cocoa before bedtime." "Maintain a consistent time to wake up each day." "Exercise 1 hour before going to bed." "Watch a television program in bed before going to sleep." Correct Answer: "Maintain a consistent time to wake up each day." The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client. Incorrect Answers: "Drink a cup of hot cocoa before bedtime." Cocoa contains caffeine, which is a stimulant that can interfere with sleep. "Exercise 1 hour before going to bed." Exercising within 2 hr of bedtime can interfere with sleep. "Watch a television program in bed before going to sleep." The client should avoid watching television in bed before going to sleep to reduce stimulation in order to promote rest. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of following actions should the nurse take? Pad the client's wrist before applying the restraints. Evaluate the client's circulation every 8 hr after application. Remove the restraints every 4 hr to evaluate the client's status. Secure the restraint ties to the bed's side rails. Correct Answer: Pad the client's wrist before applying the restraints. The use of restraints without padding can abrade the client's skin, resulting in client injury. Incorrect Answers: Evaluate the client's circulation every 8 hr after application. The nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every 15 min after initial application of restraints. Remove the restraints every 4 hr to evaluate the client's status. The nurse should remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting. Secure the restraint ties to the bed's side rails. The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury. A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm. Extinguish the fire. Evacuate the client. Confine the fire. Correct Answer: Evacuate the client. According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area. Incorrect Answers: Activate the emergency fire alarm. According to the RACE mnemonic, the second action in response to a fire is to activate the alarm. Extinguish the fire. According to the RACE mnemonic, the fourth action in response to a fire is to attempt to extinguish the fire. Confine the fire. According to the RACE mnemonic, the third action in response to a fire is to contain the fire by closing all the doors and windows in the area. The nurse should also turn off oxygen and electrical equipment in the area of the fire. A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? 107 mL/hr A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. Palpate the client's abdomen before auscultating bowel sounds. Correct Answer: Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading. Incorrect Answers: Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. The nurse should use an age-appropriate pain-rating scale, such as the visual analog or numerical scale, when assessing the pain level of an adult. The FLACC pain rating scale is used for clients aged from 2 months to 7 years old. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. The nurse should place the stethoscope at the point of maximal impulse, which is at the fifth intercostal space at the midclavicular line left of the sternum. Palpate the client's abdomen before auscultating bowel sounds. When assessing an adult client's abdomen, the nurse should auscultate bowel sounds before performing palpation in order not to change the character of the sounds. A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance CONTINUED......