ATI RN
Endocrinology Exam
1. What intervention is most important to teach the client about identifying the onset of dehydration?
- A. Measuring abdominal girth
- B. Converting ounces to milliliters
- C. Obtaining and charting daily weight
- D. Selecting food items with high water content
Correct answer: C
Rationale: The correct answer is C: Obtaining and charting daily weight. Monitoring daily weight is crucial in identifying the onset of dehydration as weight loss can be an early sign. Measuring abdominal girth (choice A) is not the most reliable method for detecting dehydration. Converting ounces to milliliters (choice B) and selecting food items with high water content (choice D) may be important for overall hydration but are not the most critical interventions for identifying the onset of dehydration.
2. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?
- A. Poor left-sided motor control
- B. Paralysis or contractures on the right side
- C. Limited visual perception of the left fields
- D. Unawareness of the existence of her left side
Correct answer: D
Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.
3. The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client's respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?
- A. Administer prescribed diphenhydramine (Benadryl).
- B. Continue to monitor the client's vital signs.
- C. Stop the infusion of packed red blood cells.
- D. Slow the infusion rate of the transfusion
Correct answer: D
Rationale: In this scenario, the client is showing signs of a potential transfusion reaction, indicated by an increased respiratory rate. The nurse's initial action should be to slow down the infusion rate of the packed red blood cells to prevent further complications. Administering diphenhydramine or stopping the infusion should not be the first actions taken, as the priority is to ensure the client's safety and prevent adverse reactions. Continuing to monitor vital signs without taking immediate action to address the increased respiratory rate would delay appropriate intervention.
4. A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?
- A. Elevate the head of the client's bed to 45 degrees
- B. Have another nurse call the Rapid Response Team
- C. Prepare to administer diphenhydramine (Benadryl)
- D. Slow the rate of the IV infusion
Correct answer: B
Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.
5. A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?
- A. Asks the client to both say and spell their full name before starting the blood transfusion
- B. Ensures that another qualified healthcare professional checks the unit before administering
- C. Checks the blood identification numbers with the laboratory technician at the Blood Bank at the time it is dispersed
- D. Ensures that all staff wear appropriate personal protective equipment during the transfusion process
Correct answer: C
Rationale: Ensuring the safety of a blood transfusion is crucial to prevent potential errors or adverse reactions. Checking the blood identification numbers with the laboratory technician at the Blood Bank when the blood is dispersed helps confirm that the correct blood product is being administered to the right patient, reducing the risk of transfusion reactions. The other choices are incorrect because asking the client to say and spell their full name (Choice A) is a part of the identification process but not specific to ensuring the safety of the blood transfusion. While having another qualified healthcare professional check the unit (Choice B) is a good practice, the direct verification with the Blood Bank technician is a more critical step in ensuring the correct blood product is administered. Choice D is irrelevant to ensuring the safety of the blood transfusion as it addresses infection control measures.
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