ATI RN
Endocrinology Exam
1. What intervention is most important to teach the client about identifying the onset of dehydration?
- A. Measuring abdominal girth
- B. Converting ounces to milliliters
- C. Obtaining and charting daily weight
- D. Selecting food items with high water content
Correct answer: C: Obtaining and charting daily weight
Rationale: The correct answer is C: Obtaining and charting daily weight. Monitoring daily weight is crucial in identifying the onset of dehydration as weight loss can be an early sign. Measuring abdominal girth (choice A) is not the most reliable method for detecting dehydration. Converting ounces to milliliters (choice B) and selecting food items with high water content (choice D) may be important for overall hydration but are not the most critical interventions for identifying the onset of dehydration.
2. As an important tool for planning a community health survey was conducted, the first tangible outcome of collaboration and teamwork with the Local Health Department and its Rural Health Units (RHUs) was observed. This later led to case findings activities via collection and examination of stools from children for suspected parasitism. Which of the following community nursing diagnoses will guide the Parish Health Team for concrete action?
- A. Parasitism as a foreseeable crisis
- B. Malnutrition as a health deficit
- C. Parasitism as a health deficit
- D. Parasitism as a health threat
Correct answer: D
Rationale: The correct answer is 'Parasitism as a health threat' as it is the most appropriate diagnosis that focuses on the immediate and significant health threat posed by parasitic infections, which can have widespread implications in a community setting. This diagnosis would guide the Parish Health Team to take concrete actions to address and mitigate the health risks associated with parasitism.
3. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?
- A. Placing cool compresses on the affected arm
- B. Elevating the affected arm on a pillow above heart level
- C. Avoiding arm exercises in the immediate postoperative period
- D. Maintaining an intravenous site below the antecubital area on the affected side
Correct answer: B
Rationale: After a mastectomy, particularly when lymph nodes are removed, there is an increased risk of lymphedema in the affected arm due to impaired lymphatic drainage. Elevating the affected arm above heart level helps promote lymphatic drainage and reduces the risk of swelling. This intervention facilitates the return of lymph fluid and helps prevent fluid accumulation in the arm.
4. A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?
- A. Allow family members to remain at the bedside.
- B. Ask the family if the client would like a fan in the room.
- C. Keep the television tuned to the client's favorite channel.
- D. Speak loudly to the client in case of hearing problems.
Correct answer: A
Rationale: Allowing the family to remain at the bedside can help calm the client with familiar voices and presence, potentially reducing restlessness and agitation. Introducing a fan may not be the priority as it can spread germs through air movement. Keeping the television on all the time may not promote rest and recovery. Speaking loudly is not advisable as it may further agitate the client. Therefore, the initial action of allowing family members to stay is most likely to provide comfort and reassurance to the client.
5. What procedure is performed prior to a blood transfusion to detect incompatibilities?
- A. Grouping and crossmatching
- B. Complete blood count
- C. D-dimer test
- D. Blood clotting test
Correct answer: Grouping and crossmatching
Rationale: Grouping and crossmatching is the procedure performed prior to a blood transfusion to determine the blood type and identify any potential incompatibilities between the donor and recipient. This process involves testing the recipient's blood for ABO and Rh antigens and crossmatching it with the donor's blood to ensure compatibility and prevent adverse reactions during the transfusion. Complete blood count, D-dimer test, and blood clotting test are other laboratory tests that serve different purposes and are not specifically done to detect incompatibilities prior to blood transfusion.
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