ATI PN 112 Final Exam 12/25
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Free ATI PN 112 Final Exam 12/25 Questions
A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?
- Loss of peripheral vision
- Decreased color perception
- Bright flashes of light
- Eyestrain
Explanation
Explanation
Cataracts cause clouding of the lens, which interferes with the transmission of light to the retina. This results in blurred vision, difficulty with glare, and a gradual fading or yellowing of colors. Clients commonly report that colors appear dull or less vivid. Loss of peripheral vision and flashes of light are associated with glaucoma or retinal disorders, while eyestrain is nonspecific and not a hallmark finding of cataracts.Correct Answer Is:
B. Decreased color perceptionThe family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- Allow the family to view the body privately.
- Have a clergy member present when the family first sees the client.
- Ask the family to return after the staff cleans the body.
- Perform postmortem care so that the body is prepared for the funeral home.
Explanation
Explanation
When a client dies unexpectedly, the priority is to support the family’s immediate grieving needs. Allowing the family to view the body privately promotes emotional expression, closure, and respects cultural and personal grieving practices. Postmortem care and involvement of clergy should be offered after the family has had an opportunity to see the client, not before. Delaying access to the body can increase distress and is not therapeutic.Correct Answer Is:
A. Allow the family to view the body privately.A nurse is collecting data from a client who has Cushing's syndrome. Which of the following findings should the nurse expect?
- Muscle hypertrophy
- Positive Chvostek's sign
- Butterfly rash
- Moon face
Explanation
Explanation
Cushing’s syndrome results from excess cortisol levels in the body. A classic physical manifestation is moon face, which refers to a round, full facial appearance caused by fat redistribution. Other common findings include truncal obesity, buffalo hump, thin skin, easy bruising, muscle wasting, hypertension, and hyperglycemia. Moon face is a hallmark sign associated with chronic corticosteroid excess.Correct Answer Is:
D. Moon faceA nurse is preparing to exit the room of a client who has a draining wound that contains methicillin-resistant Staphylococcus aureus (MRSA) and requires contact precautions. Identify the sequence the nurse should follow to remove personal protective equipment (PPE) after caring for this client.
Steps:
- Remove the gown.
- Remove the gloves.
- Remove the eyewear.
- Remove the mask.
Which of the following shows the correct order of performance?
- 2 → 1 → 3 → 4
- 1 → 2 → 3 → 4
- 2 → 3 → 1 → 4
- 3 → 2 → 1 → 4
Explanation
Explanation
Gloves are removed first because they are the most heavily contaminated. The gown is removed next since it may also carry organisms from contact with the client or environment. Eyewear is removed after protective clothing, as it is less contaminated. The mask is removed last to prevent exposure to airborne particles while removing other PPE.Correct Answer Is:
A. 2 → 1 → 3 → 4A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?
- Provide the client with a low protein diet.
- Instruct the client to cough every 4 hr.
- Advise the client to lie down after eating.
- Encourage the client to drink 8 glasses of water a day.
Explanation
Explanation
Adequate fluid intake helps thin respiratory secretions, making them easier to cough up and clear from the airways in clients with COPD. Thinner secretions improve airway clearance and reduce the risk of infection and airway obstruction. Clients with COPD typically require increased hydration unless contraindicated by another condition such as heart or kidney failure.Correct Answer Is:
D. Encourage the client to drink 8 glasses of water a day.A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client?
- Ice cream
- Hot tea
- Orange ice pop
- Cranberry juice
Explanation
Explanation
Following a tonsillectomy, the priority is to reduce pain, swelling, and the risk of bleeding. Cold, soft, non-acidic foods such as ice cream are appropriate because they help soothe the throat, promote vasoconstriction to reduce bleeding, and are easy to swallow. Hot liquids can increase bleeding, acidic foods irritate the surgical site, and red or dark-colored liquids can mask signs of postoperative hemorrhage.Correct Answer Is:
A. Ice creamA nurse is preparing to administer scheduled immunizations to a 5-year-old child. Which of the following vaccines should the nurse plan to administer?
- Haemophilus influenza type b (Hib)
- Hepatitis B (Hep B)
- Varicella (VAR)
- Meningococcal (MCV4)
Explanation
Explanation
The varicella vaccine is routinely administered in two doses, with the first dose given at 12–15 months and the second (booster) dose given at 4–6 years of age. A 5-year-old child is within the recommended age range for the second varicella immunization. Hib and Hepatitis B vaccines are typically completed during infancy, and the meningococcal vaccine (MCV4) is routinely given starting at 11–12 years of age, unless specific risk factors are present.Correct Answer Is:
C. Varicella (VAR)A nurse in the emergency department is assisting with the care of a female client.
Nurse's Notes
Client appears lethargic and reports fatigue, a decrease in appetite, and a 9.1-kg (20-lb) weight gain over the past 6 months. Client reports hair loss and numbness and tingling in fingers. Neck midline with a 1+ goiter Skin is pale, cool, and dry. Client reports constipation. Abdomen is distended. Bowel sounds are hypoactive.
Vital Signs
Temperature 35.9° C (96.6° F)
Blood pressure 88/60 mm Hg
Heart rate 58/min
Respiratory rate 14/min
Oxygen saturation 93% on room air
Diagnostic Results
0800: Cortisol (serum) 16 mcg/dL (expected reference range 5 to 23 mcg/dL)
Serum T3 60 ng/dL (expected reference range 70 to 205 ng/dL)
Serum T4 (total) 3 mcg/dL (expected reference range 5 to 12 mcg/dL)
Actions to Take | Potential Condition | Parameters to Monitor |
|---|---|---|
Prepare to administer radioactive iodine therapy | Hypothyroidism | Oxygen saturation |
Provide cooling measures | Adrenal insufficiency | Urine output |
Provide supplemental Oxygen | Hypercortisolism | Sodium level |
Request a prescription for thyroid hormone replacement | Hyperthyroidism | Manifestations of Infection |
Encourage the foods high in potassium | Bowel function | |
Which condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client's progress.
-
Condition: Hyperthyroidism
Actions: Prepare to administer radioactive iodine therapy; Provide cooling measures
Parameters to monitor: Oxygen saturation; Sodium level -
Condition: Adrenal insufficiency
Actions: Provide supplemental oxygen; Encourage foods high in potassium
Parameters to monitor: Urine output; Sodium level -
Condition: Hypothyroidism
Actions: Provide supplemental oxygen; Request a prescription for thyroid hormone replacement
Parameters to monitor: Oxygen saturation; Bowel function -
Condition: Hypercortisolism
Actions: Provide cooling measures; Request thyroid hormone replacement
Parameters to monitor: Manifestations of infection; Oxygen saturation
Explanation
Explanation
The client’s presentation is consistent with hypothyroidism, as evidenced by fatigue, weight gain, cold intolerance, dry skin, constipation, bradycardia, hypotension, hypothermia, and decreased serum T3 and T4 levels. Immediate nursing actions include providing supplemental oxygen due to decreased oxygen saturation and preparing for thyroid hormone replacement to correct the underlying hormone deficiency. Monitoring oxygen saturation evaluates cardiopulmonary status, while monitoring bowel function assesses improvement in slowed gastrointestinal motility, a common manifestation of hypothyroidism.Correct Answer Is:
C. Condition: Hypothyroidism; Actions: Provide supplemental oxygen and request a prescription for thyroid hormone replacement; Parameters to monitor: Oxygen saturation and bowel functionA nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client’s chest, the nurse should expect to hear which of the following sounds?
- Expiratory wheeze
- Fine rales
- Rhonchi
- Pleural friction rub
Explanation
Explanation
During an acute asthma exacerbation, airway inflammation, bronchoconstriction, and increased mucus production cause narrowing of the airways. This narrowing makes it especially difficult for air to move out of the lungs, leading to turbulent airflow during expiration. As a result, expiratory wheezing is the most characteristic and commonly heard lung sound in clients experiencing an asthma attack.Correct Answer Is:
A. Expiratory wheezeA nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the client’s feces?
- Fat
- Bacteria
- Blood
- Parasites
Explanation
Explanation
A stool guaiac test is used to detect the presence of occult (hidden) blood in the stool. This test helps identify gastrointestinal bleeding that may not be visible to the naked eye and is commonly used in screening for conditions such as colorectal cancer, ulcers, or other sources of gastrointestinal bleeding.Correct Answer Is:
C. BloodHow to Order
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