ATI RN
Endocrinology Exam Questions
Question 1 of 5
The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?
Correct Answer: C
Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice
A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice
B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice
D) is not relevant to addressing distended neck veins in a client sitting to eat.
Question 2 of 5
To obtain a sterile urine specimen from a client with a Foley catheter, the nurse begins by applying a clamp to the drainage tubing distal to the injection port. What does the nurse do next?
Correct Answer: C
Rationale: After clamping the drainage tubing, the next step in obtaining a sterile urine specimen from a client with a Foley catheter is to clean the injection port cap of the drainage tubing with povidone-iodine solution. This cleaning step helps prevent contamination of the urine sample. Clamping another section of the tube isn't necessary and may not be a standard practice. Inserting a syringe into the injection port to aspirate urine isn't the correct step at this point. Withdrawing 10 mL of urine and discarding it before collecting the sample isn't appropriate and may lead to an inaccurate sample.
Question 3 of 5
A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?
Correct Answer: B
Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.
Question 4 of 5
What intervention is most important to teach the client about identifying the onset of dehydration?
Correct Answer: C
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.
Question 5 of 5
When obtaining a client's vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse's best intervention?
Correct Answer: D
Rationale: The correct answer is to teach the client lifestyle modifications to decrease blood pressure. A blood pressure reading of 134/88 mm Hg falls within the prehypertension range. The initial approach to managing prehypertension involves lifestyle modifications such as dietary changes, exercise, and stress reduction techniques. Calling the healthcare provider without attempting non-pharmacological interventions first is premature. Reassessing blood pressure at the next follow-up appointment may delay necessary interventions. Administering additional antihypertensive medication is not indicated at this stage as lifestyle modifications are the first line of treatment for prehypertension.