ATI LPN
Adult Medical Surgical ATI
1. A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which pre-dialysis assessment finding should the nurse report to the healthcare provider?
- A. Serum potassium of 5.5 mEq/L.
- B. Blood pressure of 180/90 mm Hg.
- C. Heart rate of 80 beats per minute.
- D. Serum sodium of 140 mEq/L.
Correct answer: B
Rationale: The correct answer is B. A blood pressure of 180/90 mm Hg is elevated and should be reported to the healthcare provider before hemodialysis. Hypertension can have a significant impact on the effectiveness and safety of the dialysis treatment. Controlling blood pressure before the procedure is crucial to prevent complications during the dialysis session.
2. A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?
- A. Bounding erratic pulse.
- B. Regularly irregular pulse.
- C. Thready irregular pulse.
- D. No palpable pulse.
Correct answer: D
Rationale: Ventricular fibrillation is a life-threatening arrhythmia characterized by chaotic, asynchronous contractions of the ventricles, resulting in ineffective cardiac output. This leads to the absence of a palpable pulse. Nurses should be prepared to initiate immediate interventions such as defibrillation to restore normal cardiac rhythm in a client experiencing ventricular fibrillation.
3. A 48-year-old man presents with fatigue, weight gain, and cold intolerance. Laboratory tests reveal high TSH and low free T4 levels. What is the most likely diagnosis?
- A. Hypothyroidism
- B. Hyperthyroidism
- C. Thyroiditis
- D. Thyroid cancer
Correct answer: A
Rationale: The scenario describes a classic presentation of hypothyroidism, supported by the laboratory findings of high TSH and low free T4 levels. In hypothyroidism, the body's thyroid hormone levels are inadequate, leading to symptoms like fatigue, weight gain, and cold intolerance. High TSH is a compensatory mechanism by the body to increase thyroid hormone production, which is deficient, resulting in a negative feedback loop. Therefore, the correct answer is hypothyroidism.
4. A client who underwent a total hip replacement is receiving discharge teaching from a nurse. Which instruction should the nurse include?
- A. Avoid crossing your legs at the knees.
- B. Sit only in low chairs for comfort.
- C. Bend at the waist to pick up objects.
- D. Sleep on the affected side to prevent discomfort.
Correct answer: A
Rationale: The correct instruction the nurse should include is to avoid crossing the legs at the knees. This advice helps prevent dislocation of the new hip joint, which is a common concern after a total hip replacement surgery. Crossing the legs can place stress on the hip joint and increase the risk of dislocation. It is important for the client to follow this precaution to promote proper healing and reduce complications postoperatively.
5. In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?
- A. 4+ pitting edema of both lower extremities.
- B. A Braden risk assessment scale rating score of ten.
- C. Warm, dry skin with a fever of 100° F.
- D. Hypoactive bowel sounds with infrequent bowel movements.
Correct answer: B
Rationale: A low Braden score indicates a high risk for pressure ulcers, making regular turning crucial to prevent skin breakdown.
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