ATI RN
ATI Med Surg N241 Exam Questions
Extract:
Question 1 of 5
The nurse is admitting a client with liver disease who presents with dyspnea, weight gain and abdominal distention. Which order would the nurse anticipate?
Correct Answer: B
Rationale: Monitoring blood glucose is more relevant for diabetic care. A sodium diet is appropriate for managing fluid retention associated with liver disease. Bedrest may be prescribed but not as specific to the management of fluid retention. Insertion of an indwelling urinary catheter is not a standard intervention without additional justification.
Question 2 of 5
A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?
Correct Answer: A
Rationale: Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment. The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia. This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario. While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.
Question 3 of 5
The nurse is admitting a client with liver disease who presents with dyspnea, weight gain and abdominal distention. Which order would the nurse anticipate?
Correct Answer: B
Rationale: Monitoring blood glucose is more relevant for diabetic care. A sodium diet is appropriate for managing fluid retention associated with liver disease. Bedrest may be prescribed but not as specific to the management of fluid retention. Insertion of an indwelling urinary catheter is not a standard intervention without additional justification.
Question 4 of 5
While assessing the client with acute pancreatitis the nurse notes the following: skin warm and dry with inelastic turgor, hypoactive bowel sounds, nausea and vomiting for 24 hours, and amber-colored urine. Which action would the nurse take next?
Correct Answer: B
Rationale: Monitoring intake and output (I&O) is crucial for understanding the patient's fluid balance, especially after 24 hours of vomiting, which could lead to dehydration. However, it is important for fluid balance but not the immediate next step. Checking blood pressure can provide immediate information on the patient's hemodynamic status and potential hypovolemia due to fluid loss; thus, it should be assessed immediately. Assessing pain level is important for comfort, but stabilization of vital signs takes precedence. Measuring oxygen saturation is useful but less critical than assessing for potential hypotension due to dehydration.
Question 5 of 5
A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan?
Correct Answer: A
Rationale: Helps maintain muscle tone and promotes overall well-being without overstressing the body during recovery from hepatitis B. Antibiotics are not effective against viruses like hepatitis B. There is generally no need to restrict fluids in hepatitis B; adequate hydration supports overall health and liver function. A high-fat diet is not recommended for liver disease; typically, a balanced, low-fat diet is more appropriate.