ATI RN
ATI RN Custom Exams Set 4
1. The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?
- A. Assist the client in ambulating
- B. Assess the client’s bilateral pedal pulses
- C. Maintain a continuous IV heparin drip
- D. Provide clear liquids to the client
Correct answer: B
Rationale: Assessing the client’s bilateral pedal pulses is crucial at this point to monitor the perfusion to the lower extremities after abdominal aortic aneurysm repair surgery. Ambulation (Choice A) may be appropriate but should be guided by the assessment findings. Maintaining a continuous IV heparin drip (Choice C) is not typically indicated post-operatively for this type of surgery. Providing clear liquids (Choice D) may not be suitable immediately after the surgery, as the client needs time to recover before resuming oral intake.
2. A client has a new prescription for Hydrochlorothiazide. Which of the following information should the nurse include?
- A. Take the medication with food.
- B. Plan to take the medication at bedtime.
- C. Expect increased swelling of the ankles.
- D. Limit fluid intake in the morning.
Correct answer: A
Rationale: When educating a client about taking Hydrochlorothiazide, the nurse should advise taking the medication with food or after meals to prevent gastrointestinal upset. This medication is a diuretic, so it is important to maintain adequate fluid intake throughout the day to prevent dehydration. Taking it at bedtime is not necessary, and increased swelling of the ankles is not an expected side effect of this medication. Limiting fluid intake in the morning is not necessary and could lead to dehydration, which is a potential side effect of this diuretic.
3. What is the best method to monitor fluid balance in a patient receiving diuretics?
- A. Monitor daily weight
- B. Monitor intake and output
- C. Monitor blood pressure
- D. Monitor edema
Correct answer: A
Rationale: The best method to monitor fluid balance in a patient receiving diuretics is to monitor daily weight. Daily weighing is a precise way to assess changes in fluid status as it reflects variations in total body water. Monitoring intake and output (choice B) is also important but may not provide as accurate a measurement as daily weight. Monitoring blood pressure (choice C) is essential but does not directly measure fluid balance. Monitoring edema (choice D) is helpful to assess fluid status visually but may not be as sensitive as daily weight measurements in detecting subtle changes in fluid balance.
4. Which of the following organs are primarily affected by poorly managed hypertension?
- A. The bladder and urethra
- B. The brain and skin
- C. The heart and kidneys
- D. The stomach and intestines
Correct answer: C
Rationale: Poorly managed hypertension primarily affects the heart and kidneys. The heart is at risk of conditions like heart failure due to the increased workload from elevated blood pressure. The kidneys can suffer damage from longstanding hypertension, leading to kidney disease. Choices A, B, and D are incorrect because the bladder, urethra, brain, skin, stomach, and intestines are not the primary organs affected by poorly managed hypertension.
5. Which of the following disorders is more likely to be associated with blood in the stool?
- A. Gastroesophageal reflux
- B. Crohn's disease
- C. Irritable bowel syndrome
- D. Colon cancer
Correct answer: D
Rationale: The correct answer is D, Colon cancer. Colon cancer commonly presents with blood in the stool due to bleeding from the tumor. Gastroesophageal reflux (Choice A) is associated with heartburn and regurgitation of stomach contents into the esophagus. Crohn's disease (Choice B) is a type of inflammatory bowel disease that can cause symptoms like abdominal pain, diarrhea, and weight loss, but it does not typically present with blood in the stool as a primary symptom. Irritable bowel syndrome (Choice C) is a functional gastrointestinal disorder characterized by symptoms such as abdominal pain, bloating, and changes in bowel habits, but it does not usually involve blood in the stool as a prominent feature.