Exam #3 Spring 2021 Module 10 Practice ATI test

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? A. Confusion B. Blood pressure 84/50 mm Hg C. Anuria D. Petechiae

A. Confusion Rationale: Confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis.

A nurse is reviewing the laboratory results of an adolescent female client and notes a WBC count of 16,000/mm3 with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results? A. An acute infectious process B. Neutropenia C. Allergic reaction D. A resolving inflammatory process

A. An acute infectious process Rationale: The white blood cell (WBC) count is greatly elevated; however, even more telling is the elevated neutrophil count, sometimes referred to as a "shift to the left." So, with the combined information from the elevated WBC count indicating infection or inflammation and the elevated neutrophil count indicating an acute process, the appropriate analysis is that the client has an acute infectious process.

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for? A. Hemorrhage B. Infection C. Urinary retention D. Pain

A. Hemorrhage Rationale: Using the airway breathing circulation (ABC) approach to client care the nurse determines that the priority complication to monitor for is the client hemorrhaging; therefore, the nurse should monitor the client's urinary output for blood clots and bright red blood tinged urine following surgery.

A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? A. Output of burgundy colored urine B. Pulse rate of 88/min C. Oral temperature of 38.2° C (100.76° F) D. An urge to void despite having an indwelling urinary catheter

A. Output of burgundy colored urine Rationale: Output of burgundy colored urine may indicate venous bleeding, a potential complication following a TURP. Should this occur, the nurse should inform the provider and anticipate an order for increased CBI rate or manual irrigation of the catheter.

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? A. Mottled skin B. Blood pressure 115/68 mmHg C. Heart rate 160/min D. Hypokalemia

B. Blood pressure 115/68 mmHg Rationale: The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? A. Replace the catheter every 3 days. B. Check the catheter tubing for kinks or twisting. C. Irrigate the catheter once each shift. D. Clean the perineal area with an antiseptic solution daily.

B. Check the catheter tubing for kinks or twisting. Rationale: The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder.

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? A. Notify the provider. B. Check the tubing for kinks. C. Adjust the rate of the bladder irrigant. D. Irrigate the catheter.

B. Check the tubing for kinks. Rationale: When providing client care, the nurse should first use the least restrictive intervention; therefore, the nurse should check the catheter tubing for kinks. The nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting, which could occlude the catheter lumen.

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi? A. Protein in the urine B. Dehydration C. Iron deficiency D. Obesity

B. Dehydration Rationale: Dehydration can cause hypercalcemia which increases the risk for renal stone formation. Inadequate fluid intake can result in urinary stasis and promote the formation of calculi.

A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor? A. COPD B. Diabetes mellitus C. Anemia D. Osteoporosis

B. Diabetes mellitus Rationale: Diabetes mellitus is a risk for factor for a UTI due to the increased amount of glucose present in the urine.

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer? A. Danazol B. Finasteride C. Fluoxymesterone D. Methyltestosterone

B. Finasteride Rationale: Finasteride, a 5-alpha-reductase inhibitor, is used in the treatment of BPH to prevent the conversion of testosterone and to decrease prostate size.

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective? A. Increased heart rate B. Increased urine output C. Decreased blood pressure D. Decreased blood glucose level

B. Increased urine output Rationale: Dobutamine is administered to clients who have heart failure to improve their hemodynamic status. The nurse should identify an increase in client's urine output as an indication that the medication is effective.

A nurse is reviewing a client's laboratory values. Which of the following values should the nurse report to the provider? A. Hct 45% B. WBC 1,700/mm3 C. Hgb 14.7 g/dL D. Platelets 160,000/mm3

B. WBC 1,700/mm3 Rationale: A WBC count of 1,700/mm3 is a critical value that indicates the client is susceptible to infection.

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings? A. Urge incontinence B. Critically elevated prostate-specific antigen (PSA) level C. Difficulty starting the flow of urine D. Painful urination

C. Difficulty starting the flow of urine Rationale: Hesitancy or difficulty starting the flow of urine is an expected finding of BPH.

A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan? A. Enforce strict bedrest for 3 days. B. Apply fresh ice packs every 4 hr. C. Elevate the affected leg on two pillows. D. Apply antibiotic ointment to the wound with dressing changes.

C. Elevate the affected leg on two pillows. Rationale: Cellulitis is an acute inflammation of the deep connective tissue of the skin, caused by infection, The edema of the inflammatory response puts the client at risk for skin breakdown.. Elevation of the affected area and frequent repositioning reduces dependent edema and assists in the healing process.

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor? A. Hypocalcemia B. BMI less than 25 C. Family history D. Diuretic use

C. Family history Rationale: Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a client who has kidney stones for familial tendencies toward stone formation.

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. Hypotension B. Anuria C. Narrowing pulse pressure D. Decreased level of consciousness

C. Narrowing pulse pressureRationale: Pulse pressure is the difference between the systolic and diastolic blood pressures. In the initial stage of shock there is a slight increase in the diastolic blood pressure, which narrows the pulse pressure.

A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching? A. "I will wipe from the back to front with the cleansing cloth." B. "I should not collect a urine sample when I am menstruating." C. "I should let the urine cool to room temperature before sending it to the lab." D. "I need to urinate a small amount in the toilet before collecting the sample."

D. "I need to urinate a small amount in the toilet before collecting the sample." Rationale: The client should begin the stream of urine in the toilet first, and then pass the container through the urine stream to obtain the sample. This action will wash off any bacteria at the distal urethra that could contaminate the sample.

A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching? A. "I will sit on the side of the tub and soak my right leg two times every day." B. "I'll keep a heating pad on the calf of my right leg when I am lying down." C. "I'll place my leg under a heat lamp every 3 hours." D. "I'll wrap a warm, wet towel around my right calf every 4 hours."

D. "I'll wrap a warm, wet towel around my right calf every 4 hours." Rationale: Moist heat is more effective than dry heat in treating cellulitis. Moist heat relieves the manifestations of inflammation by increasing blood flow to the affected area. The nurse should instruct the client to elevate the right leg 8 to 15 cm (3 to 6 in) above the level of the heart and apply warm, moist heat to the site every 2 to 4 hr.

A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? A. Urinary retention B. Low back pain C. Incontinence D. Confusion

D. Confusion Rationale: Confusion is a clinical finding of UTIs specifically associated with older adult clients.

A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take? A. Apply cold compress to the client's flank area. B. Restrict protein intake to 2 servings per day. C. Discourage ambulation. D. Encourage intake of at least 3 L of fluids per day.

D. Encourage intake of at least 3 L of fluids per day. Rationale: The nurse should encourage the client to consume at least 3,000 mL of fluids per day to dilute the urine, increase hydrostatic pressure behind the stone, and move the calculi down the urinary tract.

A charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching? A. Keep artificial nails trimmed. B. Use alcohol-based hand rubs before administering eye drops for a client. C. Wash hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile. D. Use chlorhexidine to wash hands if the client is immunosuppressed.

D. Use chlorhexidine to wash hands if the client is immunosuppressed. Rationale: The CDC recommends health care workers use chlorhexidine for hand washing when providing care to a client who is immunosuppressed.