a nurse is reviewing the medical record of a client who is receiving morphine for pain management which of the following findings should the nurse rep
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.

2. 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.

3. A nurse is caring for a client who has deep-vein thrombosis (DVT) and is receiving heparin therapy. Which of the following laboratory values indicates that the client's heparin therapy is effective?

Correct answer: A

Rationale: An aPTT of 75 seconds indicates that heparin therapy is within the therapeutic range for a client with DVT. The activated partial thromboplastin time (aPTT) is used to monitor heparin therapy's effectiveness. Choice B, INR 1.2, is not the correct answer because INR is used to monitor the effectiveness of warfarin, a different anticoagulant, not heparin. Choice C, Hemoglobin 10 g/dL, is not a measure of heparin therapy effectiveness. Choice D, Fibrinogen level 350 mg/dL, is not a specific indicator of heparin therapy effectiveness for DVT.

4. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?

Correct answer: C

Rationale: The correct answer is to use a sterile brush to clean the inner cannula. This action is crucial to prevent infection during tracheostomy care. Choice A is incorrect as clean technique is not adequate for tracheostomy care, sterile technique is required. Choice B is incorrect as tracheostomy ties should be replaced when soiled, not routinely every 24 hours. Choice D is incorrect as tracheostomy dressings should be changed more frequently to maintain cleanliness and prevent infection.

5. A nurse is planning care for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

Correct answer: D

Rationale: The correct answer is D: Weight. Weight monitoring is essential to assess the effectiveness of desmopressin therapy, as fluid retention is a common side effect. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin therapy for diabetes insipidus. Monitoring carbohydrate intake (choice B) may be important in diabetes management but is not specific to desmopressin therapy. Hematocrit (choice C) monitoring is not a primary concern when managing diabetes insipidus with desmopressin.

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