the client with systemic sclerosis scleroderma is experiencing raynauds phenomenon what assessment finding does the nurse anticipate
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The client with systemic sclerosis (Scleroderma) is experiencing Raynaud’s phenomenon. What assessment finding does the nurse anticipate?

Correct answer: Cold and purple nailbeds

Rationale:

2. What effect does aldosterone secretion have on electrolyte levels?

Correct answer: Sodium levels are increased

Rationale: Aldosterone is a hormone that primarily acts on the kidneys to increase the reabsorption of sodium and water into the bloodstream. As a result, sodium levels are increased. Choices A, C, and D are incorrect. Aldosterone does not significantly affect calcium, potassium, or magnesium levels.

3. A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?

Correct answer: B

Rationale: A low platelet count, as seen in choice B, is concerning as it could indicate heparin-induced thrombocytopenia, a serious side effect of heparin therapy. Heparin-induced thrombocytopenia can lead to an increased risk of blood clotting, potentially causing severe complications. Monitoring platelet counts is crucial during heparin therapy to promptly identify and manage this adverse effect.

4. What is characteristic of a neonate’s vision?

Correct answer: A

Rationale: The correct answer is A: 'Pupils react to light.' Newborns' pupils do react to light, indicating that the visual pathway is functioning. However, a neonate's vision is still developing, and they can only focus on objects close to their face. Choice B is incorrect because tear glands are functional at birth. Choice C is incorrect because the blink reflex is present in neonates and helps protect their eyes. Choice D is incorrect as neonates' ciliary muscles are not fully developed.

5. While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?

Correct answer: D

Rationale: The pulsation of the tracheostomy tube with the heartbeat may indicate a tracheoinnominate artery fistula, which can lead to life-threatening hemorrhage if the artery is breached. In this scenario, as there is no active bleeding yet, the nurse should remain with the client and have another person notify the provider immediately. If the client starts to hemorrhage, the nurse should remove the tracheostomy tube and apply pressure at the bleeding site, preparing the client for urgent surgical intervention.

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