a nurse is caring for a client who has cirrhosis of the liver and is experiencing confusion which of the following laboratory values should the nurse
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

1. A client with liver cirrhosis is experiencing confusion. Which of the following laboratory values should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B: Ammonia 145 mcg/dL. An elevated ammonia level can indicate hepatic encephalopathy in clients with liver cirrhosis, leading to confusion. Bilirubin (Choice A) is within the normal range, indicating adequate liver function. Albumin (Choice C) and Hemoglobin (Choice D) levels are also within normal limits and are not directly related to the client's confusion in this scenario.

2. A client receiving morphine via patient-controlled analgesia (PCA) should have naloxone administered if their respiratory rate is below 10/min. What action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to administer naloxone if the client's respiratory rate falls below 10/min. Naloxone is used to reverse opioid-induced respiratory depression, which is a life-threatening situation. Monitoring the client's blood pressure every 4 hours (Choice A) is not the priority in this scenario as respiratory depression requires immediate attention. Asking the client to rate their pain every 2 hours (Choice B) is important for pain management but addressing respiratory depression takes precedence. Evaluating the client's use of the PCA every 4 hours (Choice D) is a routine nursing intervention but does not directly address the urgent need to reverse respiratory depression in this case.

3. A client has a new prescription for digoxin. Which of the following statements should the nurse include?

Correct answer: C

Rationale: The correct statement for the nurse to include when teaching a client about digoxin is to 'Take your pulse before taking this medication.' This is essential because clients taking digoxin need to monitor their pulse to detect signs of bradycardia, a common adverse effect of the medication. Option A is incorrect because digoxin is usually recommended to be taken with food to avoid gastrointestinal upset. Option B is incorrect because antacids can interfere with the absorption of digoxin. Option D is incorrect because contacting the provider for visual changes is important, but monitoring the pulse is crucial for digoxin administration.

4. A nurse is reviewing the laboratory results of a client who is receiving warfarin therapy for atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

Correct answer: A

Rationale: The correct answer is A. An INR of 1.8 is below the therapeutic range for a client receiving warfarin, indicating a potential risk of blood clots. This value should be reported to the provider for further evaluation and possible adjustment of the warfarin dosage. Choices B, C, and D are within normal ranges and do not directly relate to the effectiveness or safety of warfarin therapy in this scenario, making them less urgent to report.

5. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?

Correct answer: C

Rationale: Hypertension is a contraindication for kidney donation because it can negatively impact the donor's health in the long term. Hypertension poses risks during and after the donation procedure, such as affecting kidney function and potentially leading to complications for both the donor and the recipient. Amputation, osteoarthritis, and primary glaucoma are not direct contraindications for kidney donation and would not typically prevent someone from being a living kidney donor.

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