ATI RN
ATI RN Custom Nursing 221 Exam 3 Questions
Extract:
Diagnostic Results
Admission: 12 hr later.
• Lithium level 1.8 mEq/L (less than 1.5 mEq/L).
• Glucose level 90 mg/dL (74 to 106 mg/dL).
• Sodium 133 mEq/L (135 to 145 mEq/L).
• Lithium level 1.2 mEq/L (less than 1.5 mEq/L).
• Glucose level 80 mg/dL (74 to 106 mg/dL).
• Sodium 134 mEq/L (135 to 145 mEq/L).
Vital Signs
Admission:
• Temperature 37.7° C (99.9° F).
• Respiratory rate 18/min.
• Pulse rate 84/min.
• BP 130/84 mm Hg.
12 hr later:
• Temperature 37° C (98.6° F).
• Respiratory rate 16/min.
• Pulse rate 96/min.
• BP 88/50 mm Hg.
Nurses Notes
Admission:
• Gastrointestinal upset.
• Uncoordinated gait.
12 hr later:
• Client fell asleep during assessment.
• Client reports blurred vision.
• Pale, dry mucous membranes.
• Urine output 40 mL/hr.
Question 1 of 5
A nurse is collecting data from the client 12 hr later. How should the nurse interpret the following findings? For each potential finding, click to specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.
| Options | Potential Improvement | Potential Worsening |
|---|---|---|
| Vision | ||
| Lithium level | ||
| Urine output | ||
| Mucous membranes | ||
| Vital signs |
Correct Answer: A: Potential Worsening, B: Potential Improvement, C: Potential Improvement, D: Potential Worsening, E: Potential Worsening
Rationale: A: Blurred vision indicates potential neurotoxicity. B: Lithium level decrease to 1.2 mEq/L shows improvement. C: Urine output of 40 mL/hr is adequate. D: Pale, dry mucous membranes suggest dehydration. E: Hypotension (88/50 mm Hg) indicates worsening.
Extract:
Question 2 of 5
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?
Correct Answer: C
Rationale: Checking for kinks is a simple, non-invasive first step to restore drainage.
Question 3 of 5
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
Correct Answer: A
Rationale: Airway obstruction is the immediate life-threatening risk due to swelling.
Question 4 of 5
A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F) and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?
Correct Answer: B
Rationale: Shivering can counteract the cooling effect of the hypothermia blanket.
Question 5 of 5
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
Correct Answer: B
Rationale: An escharotomy involves incisions in the eschar to relieve pressure and improve circulation.