for which client situation would a consultation with a rapid response team rrt be most appropriate

ATI RN

ATI RN Custom Exams Set 3

1. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
C. 56-year-old fourth hospital day after coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization
D. 86-year-old; 48 hours postoperative repair of fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter

Correct answer: A

Rationale: The correct answer is A. This client situation presents with concerning clinical signs such as no urine output post kidney transplant, elevated temperature, tachycardia, hypotension, and restlessness, suggestive of acute renal failure and sepsis. These signs necessitate immediate intervention by the rapid response team (RRT) to address the potentially life-threatening conditions. Choice B is incorrect as the client is stable after chest tube removal and primarily anxious about going home. Choice C is incorrect as the client's symptoms are related to postoperative recovery and boredom, not indicating an urgent need for RRT consultation. Choice D is incorrect as the client post hip repair is stable, alert, and interacting normally, without signs of acute deterioration requiring RRT involvement.

2. After undergoing a pericardiocentesis, which interventions should the nurse implement?

A. Monitor vital signs every 15 minutes for the first hour
B. Evaluate the client’s cardiac rhythm
C. Record the amount of fluid removed as output
D. All of the above

Correct answer: D

Rationale: Following a pericardiocentesis, it is crucial for the nurse to monitor vital signs regularly, evaluate cardiac rhythm, and record the amount of fluid removed as output to detect any complications promptly. These interventions help in ensuring the client's safety and detecting any potential issues early. Therefore, selecting 'All of the above' (Choice D) is the correct answer as it encompasses all the essential interventions required post-pericardiocentesis. Choices A, B, and C are necessary actions to provide comprehensive care and monitor the client effectively.

3. Which of the following statements does NOT apply to a nursing plan of care?

A. It contains short-term goals
B. It is developed by the patient's physician
C. It must be continually evaluated
D. It contains long-range goals

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate needs. Choice C is also accurate as nursing plans of care need to be continually evaluated and updated to ensure they are effective. Choice D is incorrect as nursing plans of care can contain long-range goals to provide a roadmap for the patient's overall care and recovery.

4. Why may patients with hiatal hernia develop anemia?

A. Iron absorption is reduced
B. Gastritis may cause bleeding
C. Iron stores turn over more quickly
D. Patients have an aversion to foods that are good sources of iron

Correct answer: B

Rationale: The correct answer is B: Gastritis may cause bleeding. In patients with hiatal hernia, gastritis can occur due to the reflux of stomach acid into the esophagus. This gastritis can lead to gastrointestinal bleeding, resulting in anemia. Choice A is incorrect because iron absorption is not necessarily reduced in hiatal hernia. Choice C is incorrect as iron stores turnover rate is not directly related to the development of anemia in this context. Choice D is incorrect as an aversion to iron-rich foods is not a common reason for anemia in patients with hiatal hernia.

5. What is the primary goal of care for a client diagnosed with sickle cell anemia?

A. The client will call the healthcare provider if feeling ill.
B. The client will be compliant with the medical regimen.
C. The client will live as normal a life as possible.
D. The client will verbalize understanding of treatments.

Correct answer: C

Rationale: The correct answer is C: 'The client will live as normal a life as possible.' For a client with sickle cell anemia, the primary goal of care is to promote a good quality of life by managing symptoms, preventing crises, and enhancing overall well-being. Option A is incorrect as it focuses on a specific action rather than the overall goal of care. Option B is important but not the primary goal; compliance is a means to achieve better health outcomes. Option D is also important but does not address the holistic approach of helping the client maintain a normal lifestyle despite their condition.