ATI NU 160 Final Exam Spring 2025

Correct Answer A: Instruct the client to wiggle his toes

Explanation:

Assessing neurovascular status involves checking for circulation, movement, and sensation (CMS). Having the client wiggle their toes assesses motor function, which is critical for identifying possible nerve impairment or compartment syndrome following a fracture. It's a key component of the "6 P's" of neurovascular assessment: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia.

Why Other Options are Wrong:

B. Monitor the client’s calf for edema

While edema may indicate complications, it is a nonspecific sign and not a direct test of neurovascular integrity.

C. Measure the circumference of the thigh

This may help monitor swelling, but it is not a reliable or essential method for assessing neurovascular status.

D. Palpate the femoral pulse

 The femoral pulse is located in the groin, not distal to the fracture site. Neurovascular checks for a femur fracture typically focus on distal pulses (like dorsalis pedis or posterior tibial), movement, and sensation in the foot.

Correct Answer B: Sucralfate coats the ulcer and protects it from the actions of pepsin and acid.

Explanation:

B. Sucralfate coats the ulcer and protects it from the actions of pepsin and acid.

 Sucralfate is a medication that works by forming a protective barrier over the ulcer. This barrier helps protect the ulcer from the damaging effects of stomach acid and pepsin, promoting healing. It does not directly affect the acid production or the bacteria but instead protects the ulcerated area.

Why the Other Options Are Incorrect:

A. Sucralfate promotes healing of the ulcer by increasing blood flow to the area.

 Sucralfate does not increase blood flow to the ulcer. Its primary function is to form a protective barrier over the ulcer, which helps in healing, but it doesn't enhance blood circulation.

C. Sucralfate neutralizes stomach acid.

 This is incorrect because sucralfate does not neutralize stomach acid. Medications such as antacids or proton pump inhibitors (PPIs) are used for neutralizing stomach acid. Sucralfate works differently by creating a protective coating on the ulcer.

D. Sucralfate inhibits the growth of H. pylori bacteria.

 Sucralfate does not directly inhibit H. pylori growth. While H. pylori infection is a common cause of peptic ulcers, sucralfate does not target the bacteria itself. H. pylori infections are typically treated with antibiotics or proton pump inhibitors.

Correct Answer A: Previous intubation due to status asthmaticus episode

Explanation:

 Status asthmaticus is a life-threatening condition where an asthma attack does not respond to standard treatment. A history of intubation due to a past status asthmaticus episode strongly indicates severe, uncontrolled asthma and places the client at a significantly higher risk for recurrence. This history reflects a pattern of dangerous exacerbations and poor response to routine interventions.

Why Other Options are Wrong:

B. Previous stroke:

While a stroke affects neurologic and sometimes respiratory function, it is not directly related to the severity or recurrence of asthma or status asthmaticus.

C. Bronchial pneumonia:

Though pneumonia can exacerbate asthma symptoms, it is not a predictive or primary risk factor for status asthmaticus. It's an acute condition rather than a chronic indicator of asthma control.

D. Irritants and hypersensitivity to medications:

While these may trigger asthma episodes, they are not as significant or specific a risk factor for status asthmaticus as a past intubation episode, which clearly reflects prior severe respiratory compromise.

Correct Answers 

C: Broad-spectrum antibiotic

D: A clean-catch urinalysis and urine culture

E: WBC count

Explanation:

 These symptoms are consistent with a urinary tract infection (UTI). Appropriate next steps include:

C. Broad-spectrum antibiotic: Initiate treatment empirically until culture results guide specific therapy.

D. Urinalysis and urine culture: Essential to confirm diagnosis and identify the causative organism.

E. WBC count: Helps assess systemic involvement or inflammation.

Why Other Options are Wrong:

A. 0.9% sodium chloride infusion at 100 mL/hr:

 While hydration is important, IV fluids are not routinely needed for mild or outpatient UTIs unless the client is dehydrated or unable to tolerate oral fluids.

B. Foley catheter placement:

 Increases risk of introducing or worsening infection. Catheters are avoided unless there's urinary retention or another compelling need.

E. Blood cultures x2:

 Reserved for suspected urosepsis or more severe systemic infection (e.g., high fever, hypotension). Not typically required for low-grade fever and mild symptoms.

Correct Answer B: As a female, you have a shorter urethra creating an easier way for bacteria to invade your bladder.

Explanation:

The short female urethra, along with its proximity to the anus and vagina, makes it easier for bacteria (especially E. coli) to travel to the bladder, increasing the risk of urinary tract infections. This is the most clinically relevant explanation for recurrent UTIs in females.

Why Other Options are Wrong:

A. If you take too many showers you are more susceptible

 While hygiene practices can affect flora, routine showering does not significantly increase UTI risk. Overwashing is not a common cause.

C. As a female, you have more E. coli in your gastrointestinal system

 The presence of E. coli in the gut is normal for all humans. The difference in UTI risk is due to urethral length and anatomy, not bacterial abundance.

D. At your age, you have more sexual intercourse 

 This is speculative and inappropriate unless the nurse has relevant data. While sexual activity is a known risk factor, assuming it based on age is not evidence-based or respectful.

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.

Correct Answer A: Bone loss in the cortical and cancellous bones

Explanation:

Osteoporosis is a condition characterized by decreased bone density and mass, affecting both cortical (compact) and cancellous (spongy) bone. The result is porous, fragile bones that are prone to fractures. The imbalance between bone resorption and formation leads to a gradual loss of bone tissue.

Why Other Options are Wrong:

B. Buildup of inflammation in the joints:

This describes the pathophysiology of arthritis, particularly rheumatoid arthritis or osteoarthritis—not osteoporosis. Osteoporosis involves loss of bone mass, not joint inflammation.

C. Increase in calcium levels in the blood:

Osteoporosis may slightly affect serum calcium during bone resorption, but the hallmark is low bone density—not hypercalcemia. Calcium levels in the blood often remain normal.

D. Autoimmune disorder affecting the bones:

Osteoporosis is not autoimmune in nature. Autoimmune bone disorders, such as rheumatoid arthritis or lupus, are inflammatory, whereas osteoporosis is a metabolic bone disease.

Correct Answer D: Renal papilla

Explanation:

 Renal calculi (kidney stones) typically form in the renal papilla, the region of the kidney where urine is first collected before entering the calyces and renal pelvis. Here, high concentrations of calcium, oxalate, or uric acid can precipitate, forming crystals that may eventually grow into stones.

Why Other Options are Wrong:

A. Ureter:

 Stones may travel through the ureter and cause obstruction and pain, but they do not usually form there.

B. Urethra:

 The urethra is the exit point for urine. It is not a site of stone formation but can become obstructed by a stone that has traveled from the upper urinary tract.

C. Bladder:

 While stones can sometimes be found in the bladder (especially if urine is retained), primary formation usually starts in the kidney, not the bladder.

Correct Answers:

A. Assign the child to a single occupancy room

B. Designate the child for airborne isolation precautions

C. Assign the child to a negative pressure room

D. Utilize an N95 HEPA filter or respirator

E. Assign staff who have been fit-tested for the respirator mask

Explanation:

A. Assign the child to a single occupancy room

A child with active TB should be placed in a private room to prevent transmission to other clients.

B. Designate the child for airborne isolation precautions

TB is transmitted via airborne droplets, so airborne precautions are essential, including the use of isolation signage and PPE.

C. Assign the child to a negative pressure room

A negative pressure room prevents airborne particles from leaving the room, minimizing the risk of transmission to others in the facility.

D. Utilize an N95 HEPA filter or respirator

An N95 or HEPA-filtered respirator is necessary to protect staff from inhaling airborne TB bacteria.

E. Assign staff who have been fit-tested for the respirator mask

Proper fit-testing ensures the respirator provides an effective seal for protection against airborne pathogens.

Why the Other Option Is Incorrect:

F. Allow the child to use the unit playroom when it is unoccupied

Even if unoccupied, the child with active TB should not use the unit playroom due to the risk of airborne transmission in shared spaces.