Mr. Chua has developed liver cirrhosis. Nurse Bea expects alteration in which laboratory values?

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Question 1 of 5

Mr. Chua has developed liver cirrhosis. Nurse Bea expects alteration in which laboratory values?

Correct Answer: B

Rationale: Liver cirrhosis affects the liver's ability to produce proteins that are important for blood clotting, including prothrombin. Therefore, in a patient with liver cirrhosis, Nurse Bea would expect an alteration in the prothrombin time, which measures the time it takes for the blood to clot. A prolonged prothrombin time indicates impaired blood clotting function, which is commonly seen in patients with liver disease such as cirrhosis. It is an important laboratory value to monitor in patients with liver cirrhosis to assess their risk of bleeding complications.

Question 2 of 5

Which blood gas analyses are most indicative of respiratory acidosis?

Correct Answer: A

Rationale: Respiratory acidosis is indicated by a low pH and elevated PCO2, as seen in option A.

Question 3 of 5

A client with serum glucose level of 618mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?

Correct Answer: A

Rationale: The client's serum glucose level of 618mg/dl is indicative of severe hyperglycemia, likely due to uncontrolled diabetes mellitus. The client's presentation with hot dry skin, elevated heart rate, and low blood pressure suggests dehydration as a result of osmotic diuresis, which occurs in an attempt to excrete excess glucose. With an elevated heart rate and low blood pressure, it is essential to address the deficient volume to prevent further complications such as hypovolemic shock. Rehydration and fluid replacement are crucial interventions to help restore the client's fluid balance and prevent hemodynamic instability. Addressing the deficient volume related to osmotic diuresis should take the highest priority in this case.

Question 4 of 5

Which is the most reliable method for monitoring fluid balance?

Correct Answer: A

Rationale: Monitoring daily intake and output is the most reliable method for assessing fluid balance in a patient. By accurately measuring the amount of fluids taken in through foods, drinks, and IV fluids, as well as the amount of fluids eliminated through urine, stool, vomit, and other means, healthcare providers can closely track the body's fluid balance. Discrepancies between intake and output can indicate potential issues such as dehydration or fluid overload. This method provides quantitative data that can guide appropriate interventions and treatment adjustments to maintain the patient's fluid balance within normal limits. While vital signs, daily weight, and skin turgor are also important indicators of fluid status, they may not always provide as specific or accurate information as the direct measurement of intake and output.

Question 5 of 5

The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. What should the nurse recommend?

Correct Answer: A

Rationale: The nurse should recommend never heating a bottle in a microwave oven. Microwaves do not heat liquids evenly, and there is a risk of creating hot spots in the formula, which can burn the baby's mouth and throat. It is safer to heat the formula by placing the bottle in warm water or using a bottle warmer to ensure uniform heating throughout.

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