a nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia which of the following findings should the nurse report to the pro

ATI RN

ATI Exit Exam 180 Questions Quizlet

1. A nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

A. Fetal heart rate of 110/min
B. 1+ pitting edema
C. Blood pressure 138/80 mm Hg
D. Urine output of 20 mL/hr

Correct answer: D

Rationale: The correct answer is D. Urine output less than 30 mL/hr indicates decreased kidney perfusion, which is a serious complication of preeclampsia. Reporting this finding is crucial for prompt intervention. Choices A, B, and C are not the priority as fetal heart rate of 110/min, 1+ pitting edema, and blood pressure of 138/80 mm Hg are within normal limits for a client with preeclampsia at 38 weeks of gestation.

2. A client receiving a blood transfusion develops a fever. What action should the nurse take?

A. Stop the transfusion immediately.
B. Administer an antihistamine as prescribed.
C. Administer a diuretic as prescribed.
D. Increase the transfusion rate.

Correct answer: A

Rationale: When a client receiving a blood transfusion develops a fever, the priority action for the nurse is to stop the transfusion immediately. A fever during a blood transfusion may indicate a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Administering an antihistamine (choice B) or a diuretic (choice C) without assessing and addressing the potential transfusion reaction can be harmful. Increasing the transfusion rate (choice D) is contraindicated as it can exacerbate any adverse reactions the client is experiencing.

3. Which medication is used to treat opioid overdose?

A. Naloxone
B. Epinephrine
C. Lidocaine
D. Atropine

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is the standard medication for reversing opioid overdose by blocking opioid receptors. Choice B, Epinephrine, is used to treat severe allergic reactions (anaphylaxis) and cardiac arrest, not opioid overdose. Choice C, Lidocaine, is a local anesthetic used for numbing purposes and managing certain types of arrhythmias, not for opioid overdose. Choice D, Atropine, is used to treat bradycardia, organophosphate poisoning, and nerve agent toxicity, not opioid overdose.

4. What is the most important assessment for a patient post-op to monitor for complications?

A. Monitor vital signs
B. Monitor the surgical site
C. Check blood glucose levels
D. Check for abnormal breath sounds

Correct answer: A

Rationale: The correct answer is to monitor vital signs. Post-operative patients need close monitoring of their vital signs to detect early signs of complications such as changes in blood pressure, heart rate, temperature, and respiratory rate. While monitoring the surgical site is also important for signs of infection, assessing vital signs takes precedence as it provides immediate information about the patient's overall condition. Checking blood glucose levels may be essential for specific patients but is not the primary assessment for monitoring post-op complications. Checking for abnormal breath sounds is important but falls secondary to monitoring vital signs as it indicates respiratory issues rather than providing a comprehensive assessment of the patient's condition.

5. When teaching a client about nutritional intake, what should be included?

A. Carbohydrates should be at least 45% of your caloric intake.
B. Protein should be at least 55% of your caloric intake.
C. Carbohydrates should be at least 30% of your caloric intake.
D. Protein should be at least 60% of your caloric intake.

Correct answer: A

Rationale: When educating a client about nutritional intake, it is important to mention that carbohydrates should constitute at least 45% of their daily caloric intake for a balanced diet. This macronutrient provides energy and is essential for proper bodily functions. Choice B is incorrect because protein should typically account for around 10-35% of total caloric intake, not 55%. Choice C is too low for the recommended carbohydrate intake, as it should be higher at 45%. Choice D is incorrect as protein intake should generally be around 10-35% of total caloric intake, not 60%.