the client is diagnosed with pericarditis when assessing the client the nurse is unable to auscultate a friction rub which action should the nurse imp

ATI RN

ATI RN Custom Exams Set 1

1. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

A. Notify the healthcare provider
B. Document that the pericarditis has resolved
C. Ask the client to lean forward and listen again
D. Prepare to insert a unilateral chest tube

Correct answer: C

Rationale: The correct action for the nurse to take when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. This position brings the heart closer to the chest wall, making it easier to detect a friction rub if present. Notifying the healthcare provider is not necessary at this point as it may just be a matter of positioning for better auscultation. Documenting that the pericarditis has resolved is premature without proper assessment. Preparing to insert a unilateral chest tube is not indicated based on the absence of a friction rub.

2. The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow-up?

A. Client with chronic kidney disease and serum creatinine of 1.6 mg/dL
B. Client with diabetes mellitus and a glycosylated hemoglobin A (HbA1c) of 7.0%
C. Client with heart failure and a B-type natriuretic peptide (BNP) of 140 pg/mL
D. Client who is male and has anemia with hemoglobin of 16.5 g/dL and hematocrit of 45%

Correct answer: B

Rationale: An HbA1c of 7.0% in a client with diabetes mellitus indicates poor long-term glucose control, necessitating immediate follow-up. Elevated HbA1c levels suggest a higher average blood sugar over the past 2-3 months, increasing the risk of complications associated with diabetes. Choices A, C, and D do not require immediate follow-up based solely on the provided information. A serum creatinine of 1.6 mg/dL in a client with chronic kidney disease, a BNP of 140 pg/mL in a client with heart failure, and hemoglobin of 16.5 g/dL and hematocrit of 45% in a male client with anemia are within acceptable ranges or do not indicate an urgent need for intervention.

3. Which of the following statements does NOT apply to a nursing plan of care?

A. It contains short-term goals
B. It is developed by the patient's physician
C. It must be continually evaluated
D. It contains long-range goals

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate needs. Choice C is also accurate as nursing plans of care need to be continually evaluated and updated to ensure they are effective. Choice D is incorrect as nursing plans of care can contain long-range goals to provide a roadmap for the patient's overall care and recovery.

4. When does short-bowel syndrome usually occur?

A. The longitudinal muscles of the intestine contract
B. More than 50% of the small intestine is surgically removed
C. More than 50% of the large intestine is surgically removed
D. Transit time is decreased due to infection or drugs

Correct answer: B

Rationale: Short-bowel syndrome typically occurs when more than 50% of the small intestine is surgically removed. This condition leads to malabsorption issues due to the reduced length of the intestine for absorption. Choices A, C, and D are incorrect because short-bowel syndrome specifically relates to the insufficient length of the small intestine, not the contraction of longitudinal muscles, surgical removal of the large intestine, or decreased transit time due to infection or drugs.

5. The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?

A. Hold the medication
B. Administer the digoxin
C. Notify the healthcare provider
D. Recheck the apical rate in 1 hour

Correct answer: B

Rationale: An apical rate of 140 bpm is within the normal range for a newborn. Digoxin is commonly used to treat heart failure by increasing the strength and efficiency of the heart's contractions. Since the heart rate is within the normal range, there is no need to hold the medication or notify the healthcare provider. Rechecking the apical rate in an hour is unnecessary as the heart rate is not alarming. Therefore, the appropriate nursing action is to administer the digoxin.