a nurse is assessing a client for signs of anaphylaxis which of the following findings should the nurse look for
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A healthcare professional is assessing a client for signs of anaphylaxis. Which of the following findings should the healthcare professional look for?

Correct answer: B

Rationale: Hypotension is a critical sign of anaphylaxis. During anaphylaxis, there is a widespread vasodilation leading to a drop in blood pressure, which manifests as hypotension. This can be accompanied by other symptoms such as swelling, difficulty breathing, hives, and itching. Bradycardia (choice A) is not typically associated with anaphylaxis; instead, tachycardia is more common due to the body's response to the allergic reaction. Increased appetite (choice C) is unrelated to anaphylaxis, as individuals experiencing anaphylaxis often feel unwell and may have nausea or vomiting. Decreased respiratory rate (choice D) is also not a typical finding in anaphylaxis; instead, respiratory distress and wheezing are more commonly observed.

2. While documenting client care, which of the following entries should the nurse identify as an example of implementing client care?

Correct answer: B

Rationale: Administering medications as prescribed is a clear example of implementing client care because it involves carrying out a specific aspect of the care plan. Contacting the provider to report client findings is more related to assessment and communication. Reviewing the client's lab results is part of assessment and data collection. Discussing the care plan with the family is focused on collaboration and planning, rather than direct implementation.

3. A nurse is assessing a client who has schizophrenia and is experiencing negative symptoms. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Flat affect. Negative symptoms of schizophrenia involve deficits in normal emotional responses or other thought processes. These symptoms include a flat affect (reduced emotional expression), social withdrawal, and avolition (lack of motivation). Hallucinations and delusions are characteristic of positive symptoms, which involve the presence of abnormal behaviors or experiences. Paranoia is more associated with delusions rather than negative symptoms.

4. A client at 38 weeks gestation with a history of herpes simplex virus 2 is being admitted. Which of the following questions is most appropriate to ask the client?

Correct answer: B

Rationale: The most appropriate question to ask a client with a history of herpes simplex virus 2 at 38 weeks gestation is whether they have any active lesions. Active herpes lesions during labor can necessitate a cesarean delivery to prevent neonatal transmission. Asking about ruptured membranes (choice A), beta strep status (choice C), or contraction timing (choice D) is important but not the priority when managing a client with a history of herpes simplex virus 2 due to the high risk of neonatal transmission.

5. A nurse is preparing to administer an enteral tube feeding through an NG tube at 250 mL over 4 hr. The nurse should set the pump to deliver how many mL/hr?

Correct answer: C

Rationale: Calculation: 250 mL / 4 hours = 62.5 mL/hr, which should be rounded up to 63 mL/hr. This ensures the correct rate is set for continuous feeding. Choice A (60 mL/hr) is incorrect as it does not reflect the accurate calculation. Choice B (62 mL/hr) is close but does not round up to the nearest whole number as required. Choice D (65 mL/hr) is higher than the correct calculation and would deliver the feeding solution at a faster rate than prescribed.

Similar Questions

A charge nurse is teaching a new nurse how to clean surfaces contaminated with blood. Which agent should the charge nurse include in the teaching?
A client is prescribed digoxin for heart failure. Which of the following should the nurse monitor to evaluate the effectiveness of the medication?
A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?
A nurse is assessing a client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find?
A nurse is planning care for a client with a sealed radiation implant. Which intervention should the nurse implement?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses