ATI RN
ATI Proctored Nutrition Exam
1. What nursing diagnosis would be most appropriate for a patient with heart failure?
- A. risk for infection
- B. fluid volume excess
- C. impaired body temperature
- D. ineffective airway clearance
Correct answer: B
Rationale: The most appropriate nursing diagnosis for a patient with heart failure is 'fluid volume excess.' In heart failure, the heart's reduced pumping ability leads to fluid retention, causing an excess of fluid in the body. This can result in symptoms such as edema, shortness of breath, and weight gain. 'Risk for infection,' 'impaired body temperature,' and 'ineffective airway clearance' are not the most appropriate nursing diagnoses for a patient with heart failure as they do not directly relate to the pathophysiology and common issues seen in heart failure patients.
2. When is additional Vitamin C not required?
- A. Infancy
- B. Young adulthood
- C. Childhood
- D. Pregnancy
Correct answer: B
Rationale: Vitamin C requirements are increased during infancy, childhood, and pregnancy due to growth and development. However, during young adulthood, the body generally requires a consistent amount of Vitamin C as it is not undergoing rapid growth or physiological changes that necessitate an increase in Vitamin C intake.
3. A nurse is caring for a client who is 3 days postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 80/min
- B. White blood cell count of 9,000/mm3
- C. Temperature of 37.8°C (100°F)
- D. Blood pressure of 118/78 mm Hg
Correct answer: C
Rationale: A temperature of 37.8°C (100°F) should be reported to the provider as it can indicate infection, a common postoperative complication. A normal heart rate of 80/min (Choice A), white blood cell count of 9,000/mm3 (Choice B), and blood pressure of 118/78 mm Hg (Choice D) are within normal ranges and do not necessarily indicate a complication postoperatively.
4. A patient has an ankle restraint applied. Upon assessment, the nurse finds the toes a light blue color. Which action will the nurse take next?
- A. Immediately do a complete head-to-toe neurological assessment.
- B. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
- C. Place a blanket over the feet.
- D. Remove the restraint.
Correct answer: D
Rationale: The correct answer is to remove the restraint (Choice D). Cyanosis of the toes, indicated by a light blue color, suggests impaired circulation. The priority action is to ensure proper circulation by removing the restraint to prevent further compromise. Choices A and B are not the immediate actions needed for cyanosis related to impaired circulation. Choice C, placing a blanket over the feet, does not address the underlying issue of impaired circulation and could delay appropriate intervention.
5. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Massage the affected extremity to promote circulation.
- B. Elevate the affected extremity.
- C. Apply cold packs to the affected extremity.
- D. Perform range-of-motion exercises on the affected extremity.
Correct answer: C
Rationale: The correct intervention for a client with DVT is to apply cold packs to the affected extremity. Cold packs can help reduce swelling and pain by constricting blood vessels. Massaging the affected extremity can dislodge a clot and worsen the condition. Elevating the affected extremity helps with blood flow but is not the priority intervention for DVT. Performing range-of-motion exercises on the affected extremity can also dislodge a clot and is contraindicated.