ATI RN
Endocrinology Exam
1. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse’s priority?
- A. Document the observation in the chart.
- B. Measure urine specific gravity and volume.
- C. Assess the pulse and blood pressure.
- D. Assess the client’s deep tendon reflexes.
Correct answer: Assess the pulse and blood pressure.
Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.
2. The healthcare provider is preparing to administer heparin to a client. What lab value should be monitored?
- A. PT/INR
- B. aPTT
- C. Platelet count
- D. Hemoglobin
Correct answer: B
Rationale: The correct lab value that should be monitored when administering heparin is the aPTT (activated partial thromboplastin time). Heparin affects the intrinsic pathway of the coagulation cascade, and aPTT is a sensitive measure to assess the effectiveness of heparin therapy. Monitoring aPTT helps in adjusting the heparin dose to maintain the desired anticoagulant effect. PT/INR is more specific to monitor warfarin therapy, not heparin. Platelet count and hemoglobin levels are important parameters to assess bleeding tendencies and oxygen-carrying capacity but are not directly related to monitoring heparin therapy.
3. A client has been diagnosed with gastroesophageal reflux disease. The nurse interprets that the client has dysfunction of which of the following parts of the digestive system?
- A. Chief cells of the stomach
- B. Parietal cells of the stomach
- C. Lower esophageal sphincter
- D. Upper esophageal sphincter
Correct answer: C
Rationale: The lower esophageal sphincter is a functional sphincter that normally remains closed except when food or fluids are swallowed. If relaxation of this sphincter occurs, the client could experience symptoms of gastroesophageal reflux disease.
4. The nurse is teaching parents about potential causes of colic in infancy. Which should the nurse include in the teaching session?
- A. Overeating
- B. All are applicable
- C. Frequent burping
- D. Parental smoking
Correct answer: B
Rationale: Overeating, swallowing excessive air (leading to frequent burping), and parental smoking are known to contribute to colic in infants. Understimulation is not typically associated with colic.
5. A client with a pleural effusion is being assessed by a nurse. Which clinical manifestation does the nurse expect to find?
- A. Decreased breath sounds on the affected side
- B. Hyperresonance on percussion of the affected side
- C. Increased tactile fremitus on the affected side
- D. Tracheal deviation toward the affected side
Correct answer: A
Rationale: In a client with pleural effusion, decreased breath sounds on the affected side are common due to the presence of fluid in the pleural space. Hyperresonance is not expected; dullness on percussion is more likely. Tactile fremitus is typically decreased, not increased, in pleural effusion cases. Tracheal deviation away from the affected side, not toward it, can be seen with large effusions.
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