ATI RN
ATI Nproo 2100 Exam Unit 3 Fundamentals Exam Questions
Question 1 of 5
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
Correct Answer: B
Rationale: The correct answer is B: Oliguria. In hypovolemic shock, the body's fluid volume is significantly reduced, leading to decreased urine output (oliguria). This is a result of the body trying to conserve fluid to maintain blood pressure and perfusion to vital organs. Flushing of the skin (choice
A) is not an expected finding in hypovolemic shock, as the body's response is to vasoconstrict to maintain blood pressure. Bradypnea (choice
C) is not typical in hypovolemic shock, as the body usually compensates by increasing respiratory rate to improve oxygenation. Hypertension (choice
D) is not expected in hypovolemic shock, as the body tries to increase heart rate to maintain cardiac output in response to decreased blood volume.
Question 2 of 5
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
Correct Answer: A
Rationale: The correct answer is A: CD4-T-cell count 180 cells/mm3. This is the nurse's priority because it directly reflects the client's immune status and helps guide treatment decisions in HIV management. A low CD4 count indicates immunosuppression and increased risk of opportunistic infections.
Choices B, C, and D are important in HIV care but do not directly indicate the severity of the client's condition like the CD4 count does. A positive Western blot test confirms HIV infection but does not provide immediate information on the client's immune status. Platelets and WBC are important for assessing overall health but do not specifically reflect the impact of HIV on the immune system.
Question 3 of 5
A nurse is caring for a client who has a peanut allergy. The client ate peanut butter and is now experiencing anaphylaxis. Which of the following physiological responses should the nurse expect to occur?
Correct Answer: B
Rationale: The correct answer is B: Blood vessels become more permeable. During anaphylaxis, the body releases histamine causing blood vessels to dilate and become more permeable. This leads to fluid leakage from blood vessels, causing swelling and a drop in blood pressure.
Choice A is incorrect as anaphylaxis typically causes a drop in blood pressure due to vasodilation.
Choice C is incorrect because blood vessels do not constrict during anaphylaxis.
Choice D is incorrect as white blood cells are not destroyed during anaphylaxis.
Question 4 of 5
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?
Correct Answer: C
Rationale: The correct answer is C: Increased respiratory rate. In shock, the body compensates by increasing respiratory rate to improve oxygen delivery. This is the earliest indicator as the body tries to maintain perfusion. Anuria (
A) occurs later due to decreased kidney perfusion. Hypotension (
B) occurs after compensatory mechanisms fail. Decreased level of consciousness (
D) is a late sign of shock when perfusion to the brain is compromised.
Question 5 of 5
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Correct Answer: C
Rationale:
Correct
Answer: C - Blood pressure 115/68 mmHg
Rationale:
1. In the compensatory stage of shock, the body attempts to maintain blood pressure by vasoconstriction.
2. A blood pressure of 115/68 mmHg indicates the body's compensatory efforts to maintain perfusion.
3. Mottled skin (
A) is a sign of decreased perfusion, not expected in the compensatory stage.
4. A heart rate of 160/min (
B) is more likely to be seen in the progressive stage of shock.
5. Hypokalemia (
D) is not a typical finding in the compensatory stage of shock.
Summary:
- Mottled skin (
A) and heart rate of 160/min (
B) are signs of worsening shock.
- Hypokalemia (
D) is not directly related to the compensatory stage of shock.