A nurse is assessing four clients for fluid balance. Which of the following clients is exhibiting manifestations of dehydration?

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PN ATI Capstone Proctored Comprehensive Assessment 2020 B Questions

Question 1 of 5

A nurse is assessing four clients for fluid balance. Which of the following clients is exhibiting manifestations of dehydration?

Correct Answer: D

Rationale: The correct answer is D because an elevated temperature is a common manifestation of dehydration. Choices A, B, and C are not indicative of dehydration. A urine specific gravity of 1.010 is within normal range, weight gain suggests fluid overload, and a hematocrit of 45% is also within normal limits and not specifically related to dehydration.

Question 2 of 5

A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been prescribed a high-calorie, low-protein diet. Which of the following meal selections is appropriate for this client?

Correct Answer: D

Rationale: The correct answer is D: Chicken breast provides a low-fat protein source, and mashed potatoes and spinach provide high-calorie nutrients suitable for managing liver failure. Option A (Scrambled eggs, bacon, and pancakes) is high in protein, which is not suitable for a low-protein diet. Option B (Grilled cheese sandwich, potato chips, chocolate pudding) contains high protein and may not be appropriate for the client. Option C (Steak, French fries, corn) is high in protein and fat, which are not recommended for this client's dietary requirements.

Question 3 of 5

A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a catheter occlusion?

Correct Answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention indicates that the bladder is full and there is impaired elimination, which could be caused by catheter occlusion. Pain during urination (choice A) is not typically associated with catheter occlusion but may indicate a urinary tract infection. Cloudy urine (choice C) can be a sign of infection but is not specific to catheter occlusion. Blood in the catheter tube (choice D) may indicate trauma during catheter insertion but is not a typical finding in catheter occlusion.

Question 4 of 5

A nurse is caring for an older adult who has a non-palpable skin lesion that is less than 0.5 cm in diameter. Which term should the nurse use to document this finding?

Correct Answer: B

Rationale: The correct answer is B: Macule. A macule is a non-palpable skin lesion smaller than 1 cm in diameter. In this case, the skin lesion described is less than 0.5 cm, making it consistent with a macule. Vesicle (choice A) is a small blister filled with clear fluid, papule (choice C) is a solid, raised skin lesion less than 0.5 cm in diameter, and nodule (choice D) is a palpable, solid lesion larger than 0.5 cm in diameter. Therefore, choices A, C, and D describe skin lesions that do not match the characteristics of the lesion presented in the question.

Question 5 of 5

A nurse is in an acute care facility, caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?

Correct Answer: B

Rationale: The correct answer is B: 'Suppression of the urge to defecate.' Suppressing the urge to defecate can lead to constipation, especially in postoperative clients. It is essential to encourage clients to respond to the urge to defecate to prevent constipation. Increased fiber intake (Choice A) is beneficial for preventing constipation. Ambulation (Choice C) helps promote bowel motility and can reduce the risk of constipation. Daily laxative use (Choice D) may contribute to laxative dependence but is not the behavior most directly associated with increasing the risk of constipation in this scenario.

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