ATI practice

A nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical history. Which of the following intravenous fluids is contraindicated for this client? A. Whole blood B. Lactated ringers C. Dextran 40 in 0.9 sodium chloride D. 0.45% sodium chloride

0.45% sodium chloride The nurse should identify that 0.45% sodium chloride is a hypotonic solution and is contraindicated for clients who have burns. Hypotonic fluid has an osmolarity value of <270 mOsm/L which is less than the expected reference range of the osmolarity values for plasma and body fluid of 285 to 295 mOsm/L. Administering a hypotonic solution to this client can cause third-spacing of fluid

Fasting blood glucose level

70-110

A nurse is reviewing laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect? A. Decreased albumin B. Elevated hemoglobin C. Elevated lymphocytes D. Decreased cortisol

Decrease albumin A decrease in albumin level can be an indication of long-term protein depletion. Other potential conditions that result in decreased albumin levels include burns, wound drainage, and impaired hepatic function.

A nurse is assessing a client who is postoperative following a Transurethral resection ofthe prostate (TURP). After the nurse discontinues the clients urinary catheter, which of the following findings should the nurse report to the provider? A. pink-tinged urine B. Report of burning upon urination C. Stress incontinence D. Decreased urine output

Decreased urine output A decrease in urine output after TURP indicates an obstruction to urine flow by a clot or residual prostatic tissue and should be reported to the HCP

a nurse is reviewing the laboratory results of a client who has diabetes mellitus. Which of the following results indicates that the clients diabetes is controlled? A. HbA1C 8.5% B. Postprandial blood glucose 190 C. Causal blood glucoses 205 D. Fasting blood glucose 95

Fasting blood glucose 95

Postprandial blood glucose level

Less than 160

A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensation of burning and crushing pain in the toes of the absent right foot. Which of the following statements should the nurse make? A. This type of pain usually decreases over time as the limb becomes less senstivite B. Try to look at the surgical wound as a reminder the limb is gone C. Use a cold compress intermittently to decrease these pain sensations D. Grief over the lost limb can sometimes cause denial that the limb is really gone

This type of pain usually decreases over time as the limb becomes less sensitive The nurse should recognize that the client is reporting phantom limb pain a frequent complication following an amputation. The nurse should instruct the client that the sensation should decrease over time. The nurse recognize the pain, provide treatment, and handle the limb gently to decrease the risk of triggering pain.

A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following pieces of information should the nurse include in the teaching? A. You will need to continue to use some form of birth control for 6 months B. You might experience manifestations of menopause C. Do not lift anything heavier than 15 lb D. Pain or burning with urination is an expected outcome of this surgery

You might experience manifestations of menopause The nurse should inform the client that a panhysterectomy includes the removal of the uterus and ovaries, which might cause manifestations of menopause (hot flashes, night sweats and vaginal dryness)

A nurse is teaching a client who has extensive deep partial and full thickness burns and requires a topical antimicrobial medication. The goal of this medication therapy is to reduce which of the following outcomes? A. Bacterial growth B. Scarring C. Skin graft size D. pain

bacterial growth Topical antibiotic medications (particular broad-spectrum antimicrobials) help prevent bacteria from entering the body when a client has an impairment of the protective covering of the skin, as with burns. It and the dressing create a protective barrier between bacteria the exposed body tissues. This therapy helps prevent infection.

a nurse is caring for a client who has type 2 diabetes mellitus and is displaying manifestations of hyperglycemia. Which of the following findings indicates the client has hyperglycemia? A. Hunger B. Increased urination C. Cold clammy skin D. tremors

increased urination increased urination is a manifestation of hyperglycemia due to deficiency of insulin which can lead to osmotic diuresis

Casual blood glucose level

less than 200

HbA1c

less than 7%

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/L

sodium 132 The nurse should anticipate a low sodium level because sodium is trapped in interstitial space