an older adult has a diagnosis of alzheimer disease and has recently been experiencing fecal incontinence however the nurse has observed no recent cha
Logo

Nursing Elites

ATI LPN

Medical Surgical ATI Proctored Exam

1. An older adult with a diagnosis of Alzheimer's disease has been experiencing fecal incontinence, with no recent change in stool character noted by the nurse. What is the nurse's most appropriate intervention?

Correct answer: C

Rationale: The most appropriate intervention for an older adult with Alzheimer's disease experiencing fecal incontinence and no change in stool character is to toilet the client on a frequent, scheduled basis. Scheduled toileting can help manage incontinence by establishing a routine for bowel movements, which may aid in reducing episodes of fecal incontinence.

2. A patient with severe pain is prescribed morphine sulfate. What is the most important side effect for the nurse to monitor?

Correct answer: C

Rationale: When a patient is prescribed morphine sulfate, the most critical side effect for the nurse to monitor is respiratory depression. Morphine can suppress the respiratory drive, leading to inadequate ventilation and potentially life-threatening consequences. Monitoring the patient's respiratory status closely is essential to promptly identify and manage any signs of respiratory depression.

3. The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding should the provider expect?

Correct answer: A

Rationale: The correct answer is A: Increased anteroposterior chest diameter. The increased anteroposterior chest diameter, often referred to as a barrel chest, is a common finding in clients with COPD due to hyperinflation of the lungs. This occurs because of the loss of lung elasticity and air trapping, leading to a more rounded chest shape. Choices B, C, and D are incorrect. Decreased respiratory rate is not typically associated with COPD; instead, an increased respiratory rate may be seen due to the body's compensatory mechanisms. Dull percussion sounds and hyperresonance on chest percussion are not characteristic findings in COPD. Dull percussion sounds may be indicative of consolidation or pleural effusion, while hyperresonance is more commonly associated with conditions like emphysema.

4. The client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?

Correct answer: B

Rationale: In this scenario, the client is showing signs of fluid overload with tachypnea and a high pulse rate. Decreasing the saline to a keep-open rate is appropriate to prevent further fluid volume excess. This action allows for IV access to be maintained while reducing the fluid administered, helping to manage the symptoms of fluid overload.

5. An elderly client with congestive heart failure (CHF) is admitted to the hospital. Which laboratory test result should the nurse expect to find?

Correct answer: C

Rationale: In clients with congestive heart failure (CHF), impaired cardiac function can lead to decreased renal perfusion, resulting in elevated serum creatinine levels. Therefore, an increased serum creatinine level is a common laboratory finding in CHF clients, indicating possible renal impairment.

Similar Questions

The client with newly diagnosed hypertension is being taught about lifestyle modifications. Which recommendation should be made?
A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has 'little reason to live.' She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement?
A patient with type 1 diabetes is prescribed insulin glargine. What is the primary characteristic of this insulin?
An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client?
In a patient with chronic kidney disease (CKD) receiving erythropoietin therapy, what laboratory result should the nurse monitor to evaluate the effectiveness of this therapy?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses