the nurse administers 2 units of salt poor albumin to a client with portal hypertension and ascites the nurse explains to the client that this is adm

ATI RN

ATI RN Custom Exams Set 2

1. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

A. Provide nutrients
B. Increase protein stores
C. Elevate the circulating blood volume
D. Divert blood flow away from the liver temporarily

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Albumin increases the circulating blood volume, which helps to reduce ascites and improve hemodynamics in clients with portal hypertension. Choice A is incorrect because salt-poor albumin is not primarily administered to provide nutrients. Choice B is incorrect because the main purpose of administering albumin is not to increase protein stores but to address fluid shifts. Choice D is incorrect because administering albumin does not divert blood flow away from the liver temporarily; instead, it helps improve blood volume and circulation.

2. Which of the following describes the four-step method of assessment, planning, implementation, and evaluation?

A. It is a problem-focused process of continued nursing care
B. It is an open-ended process of continued nursing care
C. It is a circular process of continued nursing care
D. It is a trial-and-error process of continued nursing care

Correct answer: C

Rationale: The correct answer is C: 'It is a circular process of continued nursing care.' The four-step method of assessment, planning, implementation, and evaluation in nursing is a continuous and cyclical process. Choice A is incorrect because the method is not solely problem-focused; it involves a comprehensive approach. Choice B is incorrect as it does not capture the cyclical nature of the process. Choice D is incorrect as the method is systematic and not based on trial-and-error but rather evidence-based practice.

3. An important part of nutrition therapy for patients with cystic fibrosis is:

A. A low-fat diet to prevent steatorrhea
B. A low-sodium diet to normalize fluid status
C. A high-fiber diet to normalize bowel function
D. Pancreatic enzyme replacement therapy to help digestion

Correct answer: D

Rationale: The correct answer is D: Pancreatic enzyme replacement therapy to help digestion. In cystic fibrosis, pancreatic insufficiency leads to the malabsorption of nutrients, making it essential for patients to take pancreatic enzymes to aid in digestion. Options A, B, and C are incorrect because a low-fat diet may not provide adequate nutrition for cystic fibrosis patients, a low-sodium diet is not the primary focus of nutrition therapy in cystic fibrosis, and a high-fiber diet may exacerbate gastrointestinal symptoms due to malabsorption.

4. The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

A. The nursing assistant aspirates and measures the amount of the gastric aspirate
B. The nursing assistant elevates the head of the client’s bed 30 degrees
C. The nursing assistant warms the formula to room temperature
D. B, C

Correct answer: D

Rationale: Elevating the head of the bed to 30 degrees reduces the risk of aspiration by promoting proper digestion and preventing reflux. Warming the formula to room temperature is essential to prevent discomfort and complications. Aspirating and measuring the gastric aspirate is not a recommended nursing action for monitoring enteral feeding via a nasogastric tube, as it can introduce the risk of introducing contaminants into the feeding tube. Therefore, choices A and B are incorrect, making choice D the correct answer.

5. Warfarin (Coumadin) is an anticoagulant and interferes with the action of:

A. Platelets
B. Vitamin K
C. Calcium
D. Vitamin B12

Correct answer: B

Rationale: The correct answer is B: Vitamin K. Warfarin works by inhibiting the action of vitamin K, which is crucial for the synthesis of clotting factors in the blood. By interfering with vitamin K, warfarin decreases the production of these clotting factors, thereby prolonging the time it takes for blood to clot. This is why individuals on warfarin therapy need to monitor their vitamin K intake. Choices A, C, and D are incorrect because warfarin does not directly interfere with platelets, calcium, or vitamin B12.