a nurse is assessing a client who has cirrhosis which of the following findings should the nurse expect

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?

A. Clay-colored stools.
B. Hypertension.
C. Stridor.
D. Elevated temperature.

Correct answer: A

Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.

2. A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?

A. Cleanse the wound with povidone-iodine solution daily.
B. Irrigate the wound with hydrogen peroxide.
C. Reposition the client every 4 hours.
D. Apply a moisture barrier ointment.

Correct answer: D

Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.

3. What is the priority intervention for a patient with dehydration?

A. Administer IV fluids
B. Monitor intake and output
C. Administer oral fluids
D. Provide electrolyte replacement

Correct answer: A

Rationale: The correct answer is to administer IV fluids. This intervention is the priority as it helps rapidly restore hydration in patients with dehydration by delivering fluids directly into the bloodstream. Monitoring intake and output (choice B) is important but comes after providing immediate fluid resuscitation. Administering oral fluids (choice C) may not be sufficient for a patient with dehydration who requires rapid rehydration. Providing electrolyte replacement (choice D) is essential but often follows fluid resuscitation to correct any electrolyte imbalances resulting from dehydration.

4. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should the nurse report to the provider?

A. Potassium 4.0 mEq/L
B. Calcium 9.5 mg/dL
C. Heart rate of 60/min
D. Sodium 140 mEq/L

Correct answer: C

Rationale: The correct answer is C: Heart rate of 60/min. A heart rate of 60/min is borderline bradycardia, which can be a sign of digoxin toxicity. Digoxin can cause bradycardia, so any further decrease in heart rate should be reported promptly to the healthcare provider. Choices A, B, and D are within the normal range and not specifically related to potential digoxin toxicity, so they do not require immediate reporting.

5. Which lab test is used to assess renal function?

A. Check blood glucose levels
B. Monitor serum creatinine
C. Monitor BUN
D. Check electrolyte levels

Correct answer: B

Rationale: The correct answer is B: Monitor serum creatinine. Serum creatinine is a key indicator of renal function as it reflects the glomerular filtration rate. An increase in serum creatinine levels indicates impaired kidney function. Checking blood glucose levels (choice A) is not specific to assessing renal function but is used to diagnose diabetes. Monitoring BUN (choice C) is important but not as specific as serum creatinine in assessing renal function. Checking electrolyte levels (choice D) is essential in assessing kidney function but is not as specific as monitoring serum creatinine.