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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. What is the primary function of protein in the diet?
- A. supply energy.
- B. synthesize vitamins.
- C. build and repair tissue.
- D. store glycogen.
Correct answer: C
Rationale: The primary function of protein in the diet is to build and repair tissues. Proteins are essential for the growth, maintenance, and repair of body tissues like muscles, skin, and organs. While proteins can be a source of energy, their primary role is not to supply energy, making choice A incorrect. Choice B is also incorrect as proteins do not synthesize vitamins; rather, they are essential nutrients themselves. Choice D is inaccurate because glycogen is a form of stored glucose in the body, not a function of protein.
3. A nurse is preparing to administer a pneumococcal vaccine. Which of the following should the nurse verify?
- A. Client's allergy to eggs
- B. Client's current medications
- C. Client's vaccination history
- D. Client's blood pressure
Correct answer: C
Rationale: The correct answer is C: Client's vaccination history. Before administering a pneumococcal vaccine, the nurse should verify the client's vaccination history to ensure they are due for the vaccine. Verifying the vaccination history helps prevent unnecessary vaccinations and ensures that the client receives the appropriate immunization at the right time. Choices A, B, and D are not directly related to the administration of the pneumococcal vaccine. Checking for allergies to eggs may be important for other vaccines, but it is not specifically relevant to pneumococcal vaccination. The client's current medications and blood pressure are important for general health assessment but are not directly related to verifying the need for a pneumococcal vaccine.
4. Which assessment finding is expected with myxedema?
- A. Increased pulse rate
- B. Decreased temperature
- C. Fine tremors
- D. Weight loss
Correct answer: B
Rationale: Myxedema is characterized by a decreased metabolic rate, leading to manifestations such as decreased temperature. Therefore, the correct assessment finding expected with myxedema is a decreased temperature. Choices A, C, and D are incorrect because myxedema typically presents with a decreased pulse rate, not an increased pulse rate, absence of fine tremors (which are more common in hyperthyroidism), and weight gain rather than weight loss.
5. A person with lactose intolerance should be most careful to limit their intake of:
- A. milk
- B. yogurt
- C. cheese
- D. corn syrup
Correct answer: A
Rationale: Individuals with lactose intolerance lack the enzyme lactase needed to break down lactose, the sugar in dairy products. Milk contains a high amount of lactose, making it crucial for those with lactose intolerance to limit their intake. Yogurt and cheese, on the other hand, have lower lactose content due to the fermentation process which reduces lactose levels, making them better tolerated by many with lactose intolerance. Corn syrup, although high in sugar, does not contain lactose and is unrelated to lactose intolerance. Therefore, the correct answer is 'milk' as it is a significant source of lactose, which can trigger symptoms in individuals with lactose intolerance.
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