ATI RN
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1. Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurse�s assessment of the patient?
- A. Bedtime glucose of 140 mg/dL
- B. Noon blood glucose of 52 mg/dL
- C. Fasting blood glucose of 130 mg/dL
- D. 2-hr postprandial glucose of 220 mg/dL
Correct answer: B
Rationale:
2. A client is taking Furosemide for heart failure. Which of the following findings is a priority to report to the provider?
- A. Weight loss of 1 kg in 24 hours
- B. Blood pressure of 104/60 mm Hg
- C. Potassium level of 3.5 mEq/L
- D. Urine output of 200 mL in 8 hours
Correct answer: D
Rationale: A urine output of 200 mL in 8 hours indicates decreased kidney function, potentially due to Furosemide therapy. This finding can suggest inadequate renal perfusion and impaired drug clearance, necessitating immediate reporting to prevent further complications like electrolyte imbalances and worsening heart failure. Choice A: Weight loss may be expected in heart failure patients due to fluid retention, but it is not an immediate concern. Choice B: A blood pressure of 104/60 mm Hg is slightly low but not a priority compared to the indication of kidney dysfunction. Choice C: A potassium level of 3.5 mEq/L is within the normal range, so it does not require immediate reporting.
3. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 110/70 mm Hg
- B. Heart rate of 88/min
- C. Respiratory rate of 20/min
- D. Temperature of 37.3°C (99.1°F)
Correct answer: D
Rationale: The correct answer is D because a temperature of 37.3°C (99.1°F) is slightly elevated, indicating a possible infection or inflammatory response, which should be reported to the provider for further evaluation. Choices A, B, and C are within normal limits for a client postoperative, so they do not require immediate reporting. Elevated temperature can be a sign of infection or other complications, making it a priority for reporting and further assessment.
4. What instruction should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine for a client with poison ivy?
- A. Administer the medication with food.
- B. Chew on sugarless gum or suck on hard, sour candies.
- C. Place a humidifier at your bedside every evening.
- D. Discontinue the medication and notify your provider.
Correct answer: B
Rationale: The correct instruction for dry mouth associated with diphenhydramine is to chew on sugarless gum or suck on hard, sour candies. These actions stimulate saliva production, providing relief from dry mouth. Administering the medication with food (Choice A) may help reduce stomach upset but won't address dry mouth. Placing a humidifier at the bedside (Choice C) can help with dry air-related issues but won't specifically target dry mouth. Discontinuing the medication (Choice D) without consulting the provider is not recommended and may lead to inadequate treatment of poison ivy.
5. Rectal temperatures are indicated in which situation?
- A. In the newborn period
- B. Whenever accuracy is essential
- C. Rectal temperatures are never indicated
- D. When rapid temperature changes are occurring
Correct answer: B
Rationale: Rectal temperatures provide the most accurate measurement of core body temperature and are therefore indicated when accuracy is essential.
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