ATI NUR275 Final Assessment SU1
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Free ATI NUR275 Final Assessment SU1 Questions
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?
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The client has a history of receiving a transfusion with Rh-negative blood.
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The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus.
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The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.
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The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.
Explanation
In Rh incompatibility, the mother is Rh-negative and the fetus is Rh-positive. When fetal Rh-positive red blood cells enter the maternal circulation during delivery or other sensitizing events, the Rh-negative mother produces anti-Rh antibodies. In subsequent pregnancies, these antibodies cross the placenta and attack the Rh-positive fetal red blood cells, causing hemolysis. The breakdown of these red blood cells releases bilirubin, resulting in hyperbilirubinemia and hemolytic disease of the newborn.
Why the other options are incorrect:
A. The client has a history of receiving a transfusion with Rh-negative blood. Sensitization occurs when an Rh-negative person is exposed to Rh-positive blood, not Rh-negative blood. Receiving Rh-negative blood would not trigger anti-Rh antibody production as there is no foreign Rh antigen present.
B. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. This reverses the actual mechanism. It is the Rh-negative mother who lacks the Rh factor and produces antibodies, not the other way around. The fetus does not produce the destroying antibodies.
C. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells. Anti-A and anti-B antibodies describe ABO incompatibility, which is a separate condition from Rh incompatibility. These are different blood group systems with distinct mechanisms of hemolytic disease.
A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?
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Regular diet, no added salt
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Low-carbohydrate, low-protein diet
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Low-protein, low-potassium diet
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Low-sodium, fluid-restricted
Explanation
Acute glomerulonephritis causes inflammation of the glomeruli, leading to decreased kidney filtration, sodium and water retention, and peripheral edema. A low-sodium, fluid-restricted diet is indicated to reduce fluid retention, control edema, and decrease the workload on the kidneys. Although the urine output of 35 mL/hr is within acceptable range for a child, the presence of peripheral edema indicates fluid management is still necessary.
Why the other options are incorrect:
A. Regular diet, no added salt While avoiding added salt is a step in the right direction, a regular diet does not adequately restrict sodium or fluid intake to manage the edema and fluid retention associated with acute glomerulonephritis.
B. Low-carbohydrate, low-protein diet Carbohydrate restriction is not a primary concern in acute glomerulonephritis. Additionally, while protein may be moderately restricted in some cases, pairing it with carbohydrate restriction does not address the primary problem of sodium and fluid retention.
C. Low-protein, low-potassium diet Low-potassium restriction is more appropriate in chronic kidney disease or when hyperkalemia is present. In acute glomerulonephritis, the priority is sodium and fluid restriction rather than potassium restriction, making this diet choice incorrect for this clinical scenario.
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?
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Diminished deep-tendon reflexes
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Respiratory rate of 16/min
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Heart rate of 56/min
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Urine output of 50 mL in 4hr
Explanation
Correct Answer: (B) Respiratory rate of 16/min
A respiratory rate of 16/min is within the normal range of 12 to 20/min and indicates that magnesium sulfate has not caused respiratory depression. A respiratory rate of at least 12/min is required to safely continue the magnesium sulfate infusion. This is a key safety parameter monitored during magnesium therapy.
Why the other options are incorrect:
A. Diminished deep-tendon reflexes Diminished or absent deep-tendon reflexes are an early sign of magnesium toxicity. Normal or present deep-tendon reflexes are required before continuing the infusion. Loss of patellar reflex indicates dangerous magnesium levels and warrants stopping the infusion immediately.
C. Heart rate of 56/min A heart rate of 56/min indicates bradycardia, which can be a sign of magnesium toxicity affecting cardiac conduction. Normal heart rate must be maintained during magnesium sulfate therapy, and bradycardia warrants withholding the infusion and notifying the provider.
D. Urine output of 50 mL in 4hr Adequate urine output during magnesium sulfate therapy should be at least 25 to 30 mL/hr or 100 mL in 4 hours. An output of only 50 mL in 4 hours indicates oliguria, which reduces magnesium excretion and increases the risk of toxicity, requiring the infusion to be held and the provider notified.
A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?
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Rotate staff assignments for this client.
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Use touch to calm the client during periods of anxiety.
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Assign an assistive personnel to feed the client at mealtimes.
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Check the client's mouth after the client takes medication.
Explanation
Correct Answer: (D) Check the client's mouth after the client takes medication.
Clients with paranoid schizophrenia may believe their medications are harmful or part of a perceived threat against them. They may hide or cheek medications rather than swallowing them. Checking the client's mouth after medication administration, also called checking for cheeking, ensures medication compliance and prevents missed doses that could lead to relapse of psychotic symptoms.
Why Other Options are Incorrect:
A. Rotate staff assignments for this client. Clients with paranoid schizophrenia benefit greatly from consistency and predictability in their caregivers. Rotating staff assignments increases mistrust and anxiety in paranoid clients, as they thrive on established therapeutic relationships with familiar staff members.
B. Use touch to calm the client during periods of anxiety. Touch should be used with extreme caution or avoided entirely with clients who have paranoid schizophrenia. Unexpected physical contact can be misinterpreted as threatening or invasive, potentially escalating paranoia and agitation rather than providing comfort.
C. Assign an assistive personnel to feed the client at mealtimes. Unless the client has a physical impairment preventing self-feeding, there is no clinical indication to assign someone to feed a client with paranoid schizophrenia. This intervention is unnecessary and does not address the priority concerns of this diagnosis. Promoting independence in activities of daily living is encouraged.
Nurse's Notes
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hours. The client is receiving their fourth unit of packed red blood cells. Unit of fourth packed RBCs started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes, oxygen saturation 92% on 2L nasal cannula, and jugular vein distension noted.
Vital Signs
Temperature 37.3° C (99.1° F) Blood pressure 189/90 mm Hg Pulse rate 100/min Respiratory rate 28/min
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Actions to Take options: A. Administer diphenhydramine B. Administer epinephrine C. Administer furosemide D. Decrease the infusion rate E. Administer an antibiotic
Potential Condition options: A. Acute intravascular hemolytic reaction B. Transfusion-associated circulatory overload (TACO) C. Anaphylactic reaction D. Bacterial reaction
Parameters to Monitor options: A. Chills B. Weight C. Low back pain D. Intake and output E. Hives
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Administer diphenhydramine
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Administer epinephrine
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Administer furosemide
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Decrease the infusion rate
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Administer an antibiotic
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Acute intravascular hemolytic reaction
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Transfusion-associated circulatory overload (TACO)
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Anaphylactic reaction
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Bacterial reaction
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Chills
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Weight
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Low back pain
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Intake and output
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Hives
Explanation
Correct Answer: Condition — Transfusion-associated circulatory overload (TACO). Actions to Take — Administer furosemide and Decrease the infusion rate. Parameters to Monitor — Weight and Intake and output.
The client is most likely experiencing transfusion-associated circulatory overload (TACO). The clinical presentation of dyspnea, restlessness, bilateral crackles, oxygen saturation of 92%, jugular vein distension, and hypertension of 189/90 mm Hg occurring thirty minutes after a rapid blood transfusion at 250 cc/hr are classic signs of fluid overload from TACO. This client is receiving their fourth unit of packed RBCs, further increasing the risk.
Administering furosemide is the appropriate intervention for TACO as it is a loop diuretic that promotes fluid excretion, reducing the excess intravascular volume that is causing pulmonary congestion and respiratory distress.
Decreasing the infusion rate is a critical immediate action to reduce the rate at which fluid is being added to the already overloaded circulation, preventing further deterioration while continuing necessary transfusion therapy.
Monitoring weight is essential in TACO as rapid weight gain indicates fluid retention and worsening circulatory overload, guiding the effectiveness of diuretic therapy.
Monitoring intake and output provides ongoing data about fluid balance, kidney response to diuresis, and whether the interventions are effectively managing the fluid overload.
Why the other options are incorrect:
A. Administer diphenhydramine Diphenhydramine is used for mild allergic transfusion reactions presenting with urticaria. The client's presentation of pulmonary congestion and hypertension is not consistent with an allergic reaction.
B. Administer epinephrine Epinephrine is indicated for anaphylactic reactions characterized by hypotension, bronchospasm, and hives. The client has hypertension and signs of fluid overload, not anaphylaxis.
E. Administer an antibiotic Antibiotic administration is indicated for bacterial transfusion reactions, which typically present with high fever, rigors, and hypotension from septic shock. The client's presentation does not support a bacterial reaction.
A. Chills are associated with febrile non-hemolytic transfusion reactions or bacterial reactions, not TACO, and are not a relevant parameter to monitor in this scenario.
C. Low back pain is a hallmark symptom of acute hemolytic transfusion reactions caused by ABO incompatibility and is not relevant to monitoring TACO.
E. Hives are associated with allergic transfusion reactions and are not a parameter for monitoring circulatory overload.
Nurses' Notes
Day 1, 1400:
Client reports an injury to the right foot 1 week ago and that the wound is getting bigger and very painful.
Client has a history of type 1 diabetes mellitus, hypertension, left below the knee amputation, and atrial fibrillation.
The client weighs 92.5 kg (204 lbs).
Client reports throbbing pain in right foot as 4 on a scale of 0 to 10.
Client is alert and oriented to person, place, and time. PERRLA. Skin is warm and dry to touch. Capillary refill 1 second. Lungs clear bilaterally in anterior and posterior. Client reports no difficulty breathing. Abdomen soft and distended. Bowel sounds hypoactive in 2 quadrants. Pedal pulse +1 right foot. Wound to right lateral heel of foot measures 2 cm by 1 cm, irregular, with scant amount of green drainage.
Client's breath has a fruity smell and client states that they have been urinating frequently.
Day 1, 1800:
Client transferred to critical care unit.
Stimulus: 5 of 6
Click to highlight prescriptions that the nurse should perform immediately.
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Infuse 0.45% normal saline at 10 mL/kg/hr IV
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Regular insulin 0.1 unit/kg IV bolus
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Start regular insulin drip per protocol
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Collect blood and wound cultures
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Insert an indwelling urinary catheter
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Consult wound care
Explanation
Regular insulin 0.1 unit/kg IV bolus must be administered immediately as the first step in DKA management to rapidly begin lowering the critically elevated blood glucose of 354 mg/dL and suppress ongoing ketone production. The IV bolus is given before starting the continuous insulin drip.
Collecting blood and wound cultures must be done immediately and before administering any antibiotics to identify the causative organism responsible for the infected wound. Delaying cultures after antibiotic administration would compromise the accuracy of results and affect treatment decisions.
Inserting an indwelling urinary catheter is an immediate priority in DKA management to allow accurate hourly urine output monitoring, assess renal perfusion, and guide fluid resuscitation. Strict intake and output is critical in this acutely ill client.
Why the other options are incorrect:
A. Infuse 0.45% normal saline at 10 mL/kg/hr IV While IV fluid resuscitation is essential in DKA, the initial fluid of choice is 0.9% normal saline, not 0.45% normal saline. The 0.45% solution is hypotonic and is typically used later in management after initial volume resuscitation is established, making this prescription not appropriate to implement immediately as written.
C. Start regular insulin drip per protocol The insulin drip is initiated after the IV bolus dose of insulin has been given, not simultaneously. The bolus must precede the drip, so this is a subsequent action rather than an immediate one.
F. Consult wound care While wound care consultation is important for the infected diabetic foot wound, it is not an immediate life-saving intervention compared to managing the acute DKA. It is appropriate to initiate after the client's metabolic crisis is stabilized.
A nurse is providing teaching to a client about hypothyroidism. Which of the following potentially fatal conditions associated with hypothyroidism will the nurse include?
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Hashimoto's disease
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Sjogren's syndrome
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Myxedema coma
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Goiters
Explanation
Myxedema coma is a rare but life-threatening complication of severe untreated or undertreated hypothyroidism. It is characterized by extreme hypothermia, altered mental status, respiratory depression, bradycardia, and hypotension, and carries a high mortality rate if not recognized and treated promptly with thyroid hormone replacement and supportive care.
Why the other options are incorrect:
A. Hashimoto's disease Hashimoto's thyroiditis is an autoimmune condition that is actually the most common cause of hypothyroidism rather than a complication of it. While it leads to thyroid dysfunction, it is not itself a potentially fatal complication of hypothyroidism.
B. Sjogren's syndrome Sjogren's syndrome is an autoimmune disorder primarily affecting moisture-producing glands, causing dry eyes and dry mouth. While it can coexist with other autoimmune conditions, it is not a complication of hypothyroidism and is not potentially fatal in this context.
D. Goiters A goiter is an enlargement of the thyroid gland that can occur in hypothyroidism due to excess TSH stimulation. While a large goiter can cause compressive symptoms affecting the airway, a goiter itself is not classified as a potentially fatal complication of hypothyroidism in the same category as myxedema coma.
A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action?
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Recheck the client's temperature in 4 hr.
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Administer glucocorticoids intramuscularly.
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Prepare the client for emergency cesarean section.
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Assess the odor of the amniotic fluid.
Explanation
Correct Answer: (D) Assess the odor of the amniotic fluid.
A temperature of 38.9° C in a client with ruptured membranes is a warning sign of chorioamnionitis, an infection of the amniotic fluid and membranes. Assessing the odor of the amniotic fluid is an appropriate nursing action as foul-smelling amniotic fluid is a classic indicator of intrauterine infection, which must be identified and reported promptly to protect both mother and fetus.
Why Other Options are Incorrect:
A. Recheck the client's temperature in 4 hr. Waiting 4 hours to recheck a temperature of 38.9° C in a laboring client with ruptured membranes is inappropriate and dangerous. This finding requires immediate action and provider notification, not a delayed reassessment.
B. Administer glucocorticoids intramuscularly. Glucocorticoids such as betamethasone are administered to accelerate fetal lung maturity in preterm pregnancies between 24 and 34 weeks of gestation. At 38 weeks the fetus is full-term and lung maturity is already established, making this intervention unnecessary and inappropriate.
C. Prepare the client for emergency cesarean section. While chorioamnionitis may ultimately require expedited delivery, preparing for an emergency cesarean section is a provider decision and is not the immediate independent nursing action. The nurse must first assess the situation further, including the amniotic fluid, before escalating to surgical preparation.
A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?
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Increase the infusion rate of the IV fluid.
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Position the client on her side.
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Administer oxygen via face mask.
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Elevate the client's legs.
Explanation
Correct Answer: (B) Position the client on her side.
Late decelerations indicate uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen through the placenta. The priority nursing action is to position the client on her left side, which relieves compression of the inferior vena cava by the gravid uterus, improves venous return to the heart, increases cardiac output, and enhances placental blood flow and fetal oxygenation. This is the first and most immediate intervention.
Why the other options are incorrect:
Increasing IV fluids is an appropriate intervention for late decelerations to improve maternal circulating volume and placental perfusion. However, repositioning the client to her side is the priority first action as it most immediately addresses the compromised uteroplacental blood flow.
Administering supplemental oxygen via face mask is an important intervention to increase maternal oxygen saturation and improve fetal oxygenation. However, it is performed after repositioning the client, making it a secondary rather than the priority action.
Elevating the legs may be considered if hypotension is contributing to the late decelerations, but it is not the standard priority intervention for late decelerations. Lateral positioning is the established first-line nursing response to this fetal heart rate pattern.
A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following?
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Bone density
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Muscle mass
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Muscle strength
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Joint flexibility
Explanation
Correct Answer: (D) Joint flexibility
Passive range of motion exercises are performed by the nurse or caregiver without the client's active muscle effort. The primary purpose is to maintain and increase joint flexibility, prevent contractures, and preserve joint mobility in clients who are unable to move their extremities independently following a stroke.
Why Other Options are Incorrect:
A. Bone density Bone density is increased through weight-bearing activities and resistance exercises, not passive range of motion. Passive movement does not apply sufficient mechanical stress to the bone to stimulate bone remodeling or increase density.
B. Muscle mass Increasing muscle mass requires active resistance training and voluntary muscle contraction. Passive range of motion does not engage the muscles actively and therefore does not contribute to muscle hypertrophy or mass gain.
C. Muscle strength Muscle strength is built through active exercise where the client voluntarily contracts muscles against resistance. Since passive range of motion is performed entirely by an external force without client muscle activation, it does not increase muscle strength.
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