ATI NU 160 Final Exam Spring 2025

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 Answers:

A. Obtain orders from the health care provider to discontinue catheters as soon as possible.

C. Remind clients to urinate right away when they have an urge and to completely empty their bladder.

D. Encourage adequate fluid intake every day.

E. Promote perineal care that includes wiping the perineum from the front to the back.

Explanation:

A. Obtain orders from the health care provider to discontinue catheters as soon as possible.

Indwelling catheters significantly increase the risk for UTIs. Prompt removal reduces infection risk.

C. Remind clients to urinate right away when they have an urge and to completely empty their bladder.

Delayed urination and incomplete bladder emptying can lead to urine stasis, promoting bacterial growth and increasing UTI risk.

D. Encourage adequate fluid intake every day.

Fluids help flush bacteria from the urinary tract, decreasing infection risk.

E. Promote perineal care that includes wiping the perineum from the front to the back.

Proper perineal hygiene prevents the introduction of bacteria from the rectal area into the urethra, especially in females.

Why the Other Option Is Incorrect:

B. Continue prescribed antibiotics even if the client’s symptoms have subsided.

While this is important for treating an active UTI, it is not a preventive measure to reduce infection rates in a population. The focus here is on prevention rather than treatment adherence

Correct Answer B: Drink 3 L of fluid every day

Explanation:

 High fluid intake dilutes the urine, which helps prevent the concentration and crystallization of calcium and oxalate—key contributors to kidney stone formation. Increasing fluid intake is a primary preventive strategy for clients with a history of calcium oxalate stones.

Why Other Options are Wrong:

A. Restrict calcium intake to one serving per day:

 While it may seem intuitive, excessive calcium restriction can actually increase oxalate absorption in the gut, raising the risk of stone formation. Normal dietary calcium intake is encouraged to bind oxalate in the GI tract and prevent stone development.

B. Eat 12 oz of animal protein daily:

 High animal protein intake can increase the excretion of calcium and uric acid, both of which are risk factors for kidney stones. Clients are advised to limit, not increase, intake of animal proteins.

C. Take 3,000 mg of vitamin C daily:

 High doses of vitamin C can be metabolized into oxalate, which may lead to stone formation. This level of supplementation is excessive and potentially harmful for someone prone to calcium oxalate stones.

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 A: Mental status changes

Explanation:

 Mental status changes, such as confusion or decreased alertness, are a hallmark of severe DKA due to the effects of hyperglycemia and metabolic acidosis on the brain. Elevated ketone levels and dehydration can lead to cerebral edema and altered consciousness. This is a critical finding that suggests worsening DKA and requires urgent intervention.

Why Other Options are Wrong:

B. Dizziness:

 While dizziness may occur in many conditions, it is non-specific and not one of the key diagnostic signs of DKA. It may be present in dehydration, but mental status changes take clinical priority and are more definitive in DKA assessment.

C. Nervousness:

 This symptom is more commonly associated with hypoglycemia, not DKA. Clients with low blood sugar often feel jittery or anxious, which contrasts with the mental dulling or confusion of hyperglycemic crises like DKA.

D. Cool, clammy skin:

 This is a sign of hypoglycemia, not hyperglycemia. DKA is more often associated with dry, warm skin due to dehydration. Cool and clammy skin would not be expected in this hyperglycemic state.

Correct Answer A: You should practice deep breathing exercises.

Explanation:

 Tinnitus, or ringing in the ears, can be worsened by stress, anxiety, and certain lifestyle habits. Deep breathing exercises promote relaxation, reduce stress levels, and may help lessen the perception and severity of tinnitus episodes. Stress reduction is one of the primary non-medication strategies for managing tinnitus.

Why Other Options are Wrong:

B. You should avoid exercising.

 Avoiding exercise is not helpful and can actually worsen stress and overall health, which can contribute to tinnitus symptoms. Exercise is generally encouraged to improve circulation, reduce anxiety, and enhance well-being.

C. You can use at least 2,300 mg of sodium daily.

 High sodium intake can worsen fluid retention and affect inner ear pressure, which may aggravate tinnitus. Clients are often advised to reduce sodium as part of managing tinnitus and other inner ear disorders.

D. You can have 2 to 3 cups of coffee throughout the day.

 Caffeine can sometimes worsen tinnitus by stimulating the nervous system and increasing anxiety or excitability. Clients with tinnitus are usually advised to limit or avoid caffeine to see if it improves symptoms.

Correct Answers:

B. Exercise

C. Elevation of legs

D. Intermittent pneumatic compression pumps

E. Layered wraps

Explanation:

 Peripheral venous disease (PVD), especially chronic venous insufficiency, involves poor blood return from the legs. Management focuses on improving venous circulation, preventing stasis, and promoting return to the heart.

B. Exercise helps strengthen calf muscles, improving venous return.

C. Elevation of legs reduces venous pressure and edema.

D. Intermittent pneumatic compression pumps promote circulation and reduce the risk of venous stasis.

E. Layered wraps provide compression therapy to support venous return and reduce swelling.

Why Other Option is Wrong:

A. Ankle-brachial index test:

 This diagnostic test is used to assess arterial insufficiency, not venous disease. It helps differentiate between peripheral artery disease (PAD) and PVD, so while useful diagnostically, it is not a direct intervention for venous disease care.

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:

A. Increased respiratory rate

B. Increased heart rate

E. Increased blood pressure

Explanation:

In fluid overload, excess fluid accumulates in the intravascular and interstitial spaces. The body responds to this with compensatory mechanisms such as increased heart rate and respiratory rate to improve oxygen delivery and perfusion. Blood pressure also typically rises due to increased circulatory volume.

Why Other Options are Wrong:

C. Increased temperature

Fluid overload does not cause fever. An elevated temperature typically suggests infection or inflammation, which is not directly linked to hypervolemia.

D. Increased hematocrit

 Hematocrit levels are often decreased in fluid overload due to hemodilution—extra plasma volume dilutes red blood cells, resulting in lower hematocrit.