ATI NU 160 Final Exam Spring 2025

Correct Answer B: 0.9% normal saline IV at 50 mL/hr continuous

Explanation:

In clients with acute heart failure following an MI, fluid balance is critical. Administering 0.9% normal saline (an isotonic solution) at a continuous rate may worsen fluid overload, leading to pulmonary edema or further strain on an already weakened heart. Such a prescription could be dangerous unless clearly justified, so it requires clarification.

Why Other Options are Wrong:

A. Laboratory testing of serum potassium upon admission:

This is appropriate because potassium levels must be closely monitored in heart failure patients, especially those receiving diuretics like bumetanide, which can cause hypokalemia. It helps prevent arrhythmias and other complications.

C. Bumetanide 1 mg IV bolus every 12 hr:

Bumetanide is a loop diuretic used to reduce fluid volume in heart failure. This prescription helps relieve symptoms such as pulmonary congestion and edema. It is appropriate and expected.

D. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain:

Morphine can be used cautiously in acute MI for pain relief and to reduce anxiety and preload. While not used as frequently today, this dosage and route are within common PRN usage if monitored carefully.

Correct Answer C: Monitor for any changes in the color of your stool such as dark or black-colored stool.

Explanation:

 Dark or black-colored stools, also known as melena, can be a sign of gastrointestinal bleeding, which is a common complication of peptic ulcers. The blood from the ulcer can travel through the gastrointestinal tract and appear black or tarry when excreted in the stool. It is important for the nurse to instruct the client to monitor for these signs as they may require prompt medical attention to prevent further complications.

Why "C" is correct:

 C. "Monitor for any changes in the color of your stool such as dark or black-colored stool."

 This instruction is crucial because black or tarry stools indicate the presence of digested blood, which could be a sign of active bleeding from the ulcer. Early identification of this symptom can help prevent more severe complications, such as hypovolemic shock or the need for blood transfusions.

Why the Other Options Are Incorrect:

A. Monitor for any increase or unintentional weight gain.

 Weight gain is not typically associated with peptic ulcers, and it is not a common symptom to monitor in this context. In fact, weight loss might occur in severe cases due to difficulty eating or nausea. Therefore, weight gain is not a relevant symptom for monitoring in clients with peptic ulcers.

B. Monitor for the appearance of ecchymosis on the sides of your abdomen/pelvic areas.

 Ecchymosis (bruising) is not a typical sign of a peptic ulcer. While bleeding from an ulcer may occur, it typically presents with symptoms like dark stools, abdominal pain, and vomiting blood. Ecchymosis may be a sign of other medical conditions or trauma, but it is not directly related to peptic ulcers.

D. Monitor for any changes in the color of your urine such as maroon or red-colored urine.

 Red or maroon-colored urine may suggest urinary tract issues, such as a urinary tract infection, kidney stones, or hematuria. This is not directly related to peptic ulcers. The focus for the client with a peptic ulcer should be on signs of gastrointestinal bleeding, such as black or tarry stools, rather than changes in urine color.

Correct Answer A: Vision changes occur when the cloudy lens alters the passage of light through the eye.

Explanation:

 Cataracts develop when the lens of the eye becomes cloudy, often due to aging or long-term exposure to ultraviolet light. This cloudiness scatters or blocks light, leading to blurry or dim vision. It does not involve the retina or intraocular pressure. Cataract-related vision changes are usually gradual and painless.

Why Other Options are Wrong:

B. Vision changes occur when blood vessels leak fluid or blood under a portion of the retina.”

 This describes conditions like diabetic retinopathy or macular degeneration, not cataracts. These disorders involve vascular changes, while cataracts involve changes to the lens.

C. Vision changes occur when retinal tissue pulls away from the blood vessels in the eye.”

 This describes a retinal detachment, a medical emergency unrelated to cataracts.

D. Vision changes occur when pressure in the eye is increased due to a decrease of aqueous humor.”

 This is characteristic of glaucoma, not cataracts. Cataracts do not affect intraocular pressure.

Correct Answer B: Massaging her legs

Explanation:

 Massaging the legs of a client at risk for VTE can dislodge a thrombus (clot) and cause it to travel to the lungs, resulting in a pulmonary embolism—a life-threatening condition. This action is considered unsafe and should be avoided in clients at risk for or suspected of having deep vein thrombosis (DVT).

Why Other Options are Wrong:

Elevating her feet:

 This is a recommended action to promote venous return and prevent blood stasis. Elevation can help reduce swelling and improve circulation in the lower extremities.

Flexing her ankles:

 Ankle pumps or flexing exercises are part of VTE prophylaxis. These movements activate the calf muscles and promote venous return, reducing clot formation risk.

Ambulating soon after surgery:

 Early ambulation is encouraged postoperatively to prevent complications such as DVT and pulmonary embolism. It enhances circulation and reduces the risk of clot formation.

Correct Answer C: My vision is blurry and objects are hazy.

Explanation:

Cataracts cause a clouding of the lens, leading to blurry, hazy vision, sensitivity to light, and decreased night vision. It often progresses slowly and is a common age-related change in the eye.

Why Other Options are Wrong:

A. I can’t see objects from the sides of my eyes.

This is a symptom of glaucoma, which affects peripheral vision due to increased intraocular pressure damaging the optic nerve.

B. There are dark spots moving around in my eye.

These are known as floaters and can be normal with age, but are more concerning when associated with retinal detachment of vitreous hemorrhage.

D. I can’t see anything in the middle part of my eyes.

This suggests macular degeneration, where central vision deteriorates due to damage to the macula, not cataracts.

Correct Answer B: Mask

Explanation:

B. Mask

Influenza is transmitted primarily through respiratory droplets. The nurse should instruct the client to wear a mask to prevent spreading the virus when coughing, sneezing, or talking. This helps protect others from airborne droplets that can transmit infection.

Why the Other Options Are Incorrect:

A. Goggles

Goggles are not required for clients with influenza. They are typically worn by healthcare providers to protect their eyes from splashes during procedures.

C. Gloves

Gloves are used by healthcare personnel when there is potential for contact with bodily fluids or contaminated surfaces. Clients do not need to wear gloves.

D. Gown

Gowns are worn by healthcare providers to protect their clothing from contamination. Clients with influenza do not need to wear gowns.

Correct Answer C: Excessive daytime sleepiness

Explanation:

 Obstructive sleep apnea (OSA) involves repeated episodes of upper airway obstruction during sleep, leading to interrupted breathing and poor sleep quality. As a result, clients with OSA commonly experience excessive daytime sleepiness, fatigue, difficulty concentrating, and irritability. This is one of the hallmark symptoms and a key reason why clients seek medical evaluation.

Why Other Options are Wrong:

Chest pain:

 While OSA can be associated with cardiovascular complications, chest pain is not a typical presenting symptom. It requires evaluation for other causes.

Elevated mood:

 OSA is more often associated with mood disturbances like depression or irritability—not elevated mood. Sleep disruption tends to worsen emotional stability.

Increased appetite:

 OSA does not directly cause increased appetite. In fact, some people may experience weight gain due to fatigue-related inactivity, but increased appetite is not a direct symptom of the disorder.

Correct Answer D: Candidiasis

Explanation:

 Oral candidiasis (thrush) is a fungal infection caused by Candida albicans. It is common in immunosuppressed individuals, including those on corticosteroids, antibiotics, or chemotherapy. The defining characteristic is white, milky plaques in the mouth that do not scrape off easily. It can cause pain, difficulty eating, and a burning sensation.

Why Other Options are Wrong:

A. Dermatitis:

 Dermatitis affects the skin, not the mucous membranes of the mouth. It would not present with oral plaques or interfere with eating.

B. Herpes simplex:

 Herpes simplex causes painful vesicles that rupture and form ulcers, not white plaques. The lesions are typically localized to lips and oral mucosa but appear red and ulcerated, not milky and stuck.

C. Squamous cell carcinoma:

 Oral squamous cell carcinoma may present as non-healing sores, lesions, or lumps, but not as diffuse white plaques that resist removal. It is more common in older adults with tobacco use histories.

Correct Answer C: Insulin is stable at room temperature for one month.

Explanation:

Most insulins are safe to store at room temperature (below 86°F/30°C) for up to 28–30 days once opened. This makes it easier for clients to carry and use insulin without constantly needing refrigeration, while still maintaining efficacy.

Why Other Options are Wrong:

A. All insulins can be mixed in the same syringe.

Not all types of insulin are compatible for mixing. For example, long-acting insulins like glargine or detemir should not be mixed with other types. Mixing incompatible insulins can alter absorption and effectiveness.

B. Storing insulin in the freezer will prolong its stability.

Freezing insulin destroys its molecular structure, rendering it ineffective and potentially dangerous. Insulin should never be frozen.

D. Clients with type 1 diabetes mellitus should keep backup medication and supplies in their car.

This is unsafe because temperature fluctuations in a car (especially extreme heat or cold) can degrade insulin. Backup supplies should be kept in a temperature-controlled environment.