a nurse is caring for a client who has dehydration which of the following findings should the nurse expect a nurse is caring for a client who has dehydration which of the following findings should the nurse expect
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Nursing Elites

ATI RN

ATI Exit Exam RN

1. A nurse is caring for a client who has dehydration. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: Correct! Dry mucous membranes are a common finding in clients with dehydration. Dehydration leads to reduced fluid volume in the body, resulting in dryness of mucous membranes, decreased skin turgor, and thirst. Bradycardia (slow heart rate) is not typically associated with dehydration, as the body tries to compensate for decreased fluid volume by increasing heart rate. Hypotension (low blood pressure) is a possible finding in dehydration due to reduced circulating volume. Tachypnea (rapid breathing) is more commonly seen in conditions like respiratory distress or metabolic acidosis, rather than dehydration.

2. The Acceptable Macronutrient Distribution Ranges state that half of your calories should come from protein.

Correct answer: B

Rationale: The statement is FALSE. The Acceptable Macronutrient Distribution Ranges recommend that 10-35% of daily calories come from protein, not half. The remaining calories should be derived from a combination of carbohydrates and fats to ensure a balanced diet. Choosing option A is incorrect because it misinterprets the recommended percentage for protein intake. Options C and D are left blank as they are not applicable to the question.

3. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: The correct first action for the nurse to take when preparing to administer a unit of packed RBCs is to check the client's identification band. This step is crucial to ensure that the correct blood is administered to the right client, preventing any errors or adverse reactions. Verifying the provider's prescription, priming the IV tubing, and obtaining the client's vital signs are important steps in the process but should follow the initial identification check to prioritize patient safety.

4. A nurse is assessing a client who is 1 day postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: Abdominal distention and rigidity may indicate a postoperative complication, such as bowel obstruction or peritonitis, and should be reported to the provider. While monitoring urine output, heart rate, and wound drainage are essential postoperative assessments, they are not as concerning as abdominal distention and rigidity, which could signal a more urgent issue requiring immediate attention.

5. What are the signs and symptoms of Increased Intracranial Pressure (IICP)?

Correct answer: A

Rationale: The correct answer is A: Irritability, confusion, restlessness. These are common signs of Increased Intracranial Pressure (IICP) as they result from the increased pressure on brain tissue. Choices B, C, and D are incorrect. Fatigue and shortness of breath (SOB) are not typical symptoms of IICP. Changes in pupillary response can be seen in other conditions but are not specific to IICP. Elevated blood pressure is not a common sign of IICP.

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