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. When the client finds antiembolism stockings uncomfortably tight, what is the nurse's best action?
- A. Remove the stockings for an hour to relieve the pressure
- B. Pull the stockings down so that they are not constricting
- C. Measure the client's calf to ensure that they are the correct size
- D. Teach the client the purpose of wearing the stockings
Correct answer: D
Rationale: The correct action for the nurse to take when a client finds antiembolism stockings uncomfortably tight is to teach the client the purpose of wearing the stockings. This educates the client on the importance of the stockings in preventing blood clots and encourages compliance. Removing the stockings or pulling them down may compromise their effectiveness. Measuring the client's calf size is not necessary in this situation as the discomfort is due to tightness, not incorrect sizing.
3. The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (Select one that doesn't apply.)
- A. Use sterile gloves and gowns whenever the nursing staff is in contact with the client.
- B. Keep a blood pressure cuff, thermometer, and stethoscope in the client's room for his or her use only
- C. Request that the family take home the fresh flowers that are at the client's bedside
- D. Assist the client with meticulous oral care after meals and at bedtime.
Correct answer: A
Rationale:
4. The healthcare professional is assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?
- A. Absence of pedal edema in the lower legs.
- B. Absence of complaints of sexual dysfunction.
- C. No indication of renal impairment.
- D. Blood pressure reading of 148/94 mm Hg.
Correct answer: C
Rationale: The correct answer is 'No indication of renal impairment.' Effective hypertension management aims to prevent complications such as renal impairment. Checking for signs of kidney issues, like abnormal renal function tests, is crucial in monitoring the client's condition. Choices A, B, and D are not specific indicators of effective hypertension management. Pedal edema, sexual dysfunction, and a single blood pressure reading are important but do not solely determine the effectiveness of managing hypertension.
5. 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.
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