ATI NUR 109 Final Assessment Exam

The correct answer is C: Respiratory rate 8/min

Explanation:

A respiratory rate of 8 breaths per minute is considered abnormally low and is a sign of respiratory depression, which is a serious adverse effect of opioid medications like morphine sulfate. Opioids suppress the respiratory centers in the brain, and close monitoring is required after administration—especially within the first 15 to 30 minutes when peak effects may occur. Respiratory depression is a medical emergency that requires immediate intervention, such as stopping the opioid, stimulating the patient, and possibly administering naloxone, an opioid antagonist.

Why the other options are incorrect:

A. Sleepy, but arousing when her name is called

This level of sedation is expected after morphine administration and is not considered an adverse effect as long as the client is easily arousable and maintains stable vital signs.

B. SaO₂ 94%

An oxygen saturation of 94% is within the acceptable range for most patients and is not considered an adverse effect.

D. Pain level of 6 on a scale from 0 to 10

This indicates that the morphine may not yet be fully effective, or the dose may be insufficient for the client’s pain level. However, this is not an adverse effect, but rather an issue of effectiveness.

Summary:

A respiratory rate of 8/min (Option C) indicates respiratory depression, which is a potentially life-threatening adverse effect of IV morphine sulfate and requires prompt nursing action.

The correct answers are:

C. Socioeconomic status

D. Cultural background

E. Social support

Explanation:

External variables are factors outside the individual that influence health and illness. These include the patient’s socioeconomic status, which affects access to healthcare, resources, and living conditions. The cultural background shapes beliefs, values, and health practices that impact illness management and compliance. Social support from family, friends, and community provides emotional, financial, and practical assistance, which can influence recovery and well-being.

Why the other options are incorrect:

A. Patient’s perception of illness: This is an internal variable, reflecting the individual’s personal understanding and feelings about their condition.

B. Patient’s coping skills: This is also an internal variable, relating to how the patient manages stress and illness mentally and emotionally.

Summary:

Correct answers: C, D, and E. To assess the impact of external variables, the nurse should evaluate the patient’s socioeconomic status, cultural background, and social support system.

The correct answer is C: Americans of African descent

Explanation:

Americans of African descent have the highest prevalence of hypertension in the United States. They are more likely to develop high blood pressure at an earlier age and experience more severe complications, including stroke, kidney failure, and heart disease. Due to these health disparities, this group is a priority population for community-based blood pressure screenings and education initiatives.

Why the Other Choices Are Incorrect:

A. Non-Hispanic Caucasians

While hypertension affects this group, the prevalence and severity are not as high as in Americans of African descent.

B. Americans of European descent

This overlaps with Option A and still does not represent the highest-risk group for hypertension-related health concerns.

D. Americans of Asian descent

This population does have health concerns related to cardiovascular disease, but hypertension is less prevalent compared to Americans of African descent.

Summary:

The group the RN will most likely address is C. Americans of African descent, due to their significantly higher risk for hypertension and its associated complications.

The correct answer is C: Creatinine

Explanation:

Serum creatinine is the most specific and reliable indicator of kidney function. It is a waste product generated from normal muscle metabolism and is excreted entirely by the kidneys. When kidney function declines, creatinine accumulates in the blood, making it a key marker for assessing how well the kidneys are filtering. Elevated serum creatinine strongly suggests impaired glomerular filtration rate (GFR) and is used to stage chronic kidney disease (CKD) or detect acute kidney injury (AKI). It is routinely ordered when evaluating renal function and is also used in calculating the estimated GFR (eGFR), which provides a more complete picture of kidney health.

Why the other options are incorrect:

A. BUN (Blood Urea Nitrogen):

Although BUN is also used to assess kidney function, it is less specific than creatinine. BUN levels can be influenced by factors such as dehydration, high protein intake, or gastrointestinal bleeding, which makes it a less reliable standalone indicator. It is often interpreted alongside creatinine for a more accurate assessment.

B. Potassium:

Potassium levels can be affected by kidney dysfunction because the kidneys help regulate potassium balance. However, potassium is a secondary effect of kidney dysfunction rather than a primary measure of kidney function. Abnormal potassium levels indicate that the dysfunction has progressed to affect electrolyte regulation but do not assess filtration ability directly.

D. CBC (Complete Blood Count):

A CBC evaluates red and white blood cell counts and hemoglobin/hematocrit levels. It is not used to measure kidney function directly. While anemia may result from chronic kidney disease (due to reduced erythropoietin production), a CBC is not a primary test for kidney evaluation.

Summary:

Correct answer: C. Creatinine. Serum creatinine is the most specific and direct marker of kidney function, used to evaluate how efficiently the kidneys are filtering waste from the blood. It is central to diagnosing and monitoring kidney disease.

The correct answer is B: Listen to lung sounds bilaterally

Explanation:

When assessing lung sounds, it is essential to listen to both sides of the chest in a symmetrical pattern—from apex to base—so the nurse can compare sounds between the right and left lungs. This comparison helps detect asymmetries that may indicate abnormal findings such as consolidation, fluid, or collapsed lung tissue. Assessing bilaterally ensures that subtle differences are not missed and provides a more complete picture of the patient’s respiratory status.

Why the other options are incorrect:

A. Have the patient hold their breath

This would prevent the nurse from hearing airflow, which is the very sound being assessed. Breath sounds are best heard during active inhalation and exhalation.

C. Have the patient inhale and exhale through the nose

Instructing the patient to breathe through the mouth is preferred because it produces more audible lung sounds. Nasal breathing is quieter and may make it harder to hear subtle abnormalities.

D. Listen through the patient’s gown

This can muffle or distort lung sounds, reducing accuracy. The stethoscope should be placed directly on the skin to obtain clear and reliable assessments.

Summary:

Option B is correct because bilateral assessment of lung sounds allows for accurate comparison and identification of abnormal respiratory findings.

The correct answer is B: Stage II

Explanation:

A Stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow open ulcer with a red-pink wound bed, without slough, or as an intact or ruptured serum-filled blister. This matches the scenario described.

Why the other options are incorrect:

A. Stage I

This stage involves intact skin with non-blanchable redness. There is no open wound or loss of dermis.

C. Stage III

Stage III involves full-thickness tissue loss, possibly exposing subcutaneous fat, but not bone, tendon, or muscle. There may also be slough, which is not present here.

D. Stage IV

This is full-thickness tissue loss with exposed bone, tendon, or muscle. The described wound does not reach that depth.

E. Unstageable

A wound is unstageable when the base is covered with slough or eschar, preventing depth assessment. In this case, the wound bed is clearly visible and not obscured.

Summary:

Option B is correct because the wound described has partial-thickness loss of dermis, a red-pink bed, and no slough, which are hallmark signs of a Stage II pressure ulcer.

The correct answer is C: Continuous urine drainage that bypasses urethra

Explanation:

A suprapubic catheter is inserted surgically through the abdominal wall into the bladder, and it is used for long-term or continuous urinary drainage in clients who cannot use a urethral catheter. This type of catheter bypasses the urethra, making it useful for patients with urethral trauma, strictures, prostate issues, or long-term catheterization needs.

Why the other options are incorrect:

A. Immediate drainage of bladder followed by removal of catheter

This describes a straight (intermittent) catheter, not a suprapubic catheter.

B. Continuous kidney drainage

Kidney drainage would involve a nephrostomy tube, not a suprapubic catheter. The suprapubic catheter drains the bladder, not the kidneys.

D. Continuous bladder irrigation

While bladder irrigation can be done through a suprapubic catheter, it is not the primary purpose. Continuous bladder irrigation is more commonly associated with three-way urinary catheters, typically used after bladder surgery or prostate procedures.

Summary:

Option C is correct because a suprapubic catheter provides continuous urinary drainage while bypassing the urethra, making it ideal for patients with long-term or complex urinary retention issues.

The correct answer is D: Are you taking iron supplements?

Explanation

Black stool (also known as melena) can be caused by iron supplements, which commonly darken the stool as a benign side effect. It’s important to determine whether this discoloration is due to supplementation or something more serious, such as upper gastrointestinal bleeding, which also causes black, tarry stools due to digested blood.

Asking about iron supplements helps the RN differentiate between a harmless cause and a potential clinical emergency. If the patient is not taking iron, further evaluation would be necessary to rule out bleeding in the GI tract.

Why the other options are incorrect:

A. Are you straining when you defecate?

Straining is more associated with constipation or hemorrhoids, not with black stool.

B. Do you take laxatives?

Laxatives typically cause changes in stool consistency or frequency, not usually black color. Some laxatives may cause loose stools, but not darkening.

C. Do you have hemorrhoids?

Hemorrhoids typically cause bright red blood in or on the stool, not black stool. Asking this would be more appropriate for red or bloody stools, not melena.

Summary:

Option D is correct because iron supplements are a common cause of black stool, and identifying their use helps the RN determine if the discoloration is benign or needs further investigation.

The correct answer is C: Right ventricular heart failure

Explanation:

Right ventricular (right-sided) heart failure causes systemic venous congestion, leading to peripheral edema, especially in the lower extremities. This type of edema often worsens during the day when the person is upright and gravity pulls fluid downward, and improves at night when the person is lying down, allowing fluid to redistribute and be reabsorbed.

Why the other options are incorrect:

A. Pulmonary edema

Pulmonary edema is associated with fluid accumulation in the lungs, leading to symptoms such as shortness of breath, crackles, and cough, not peripheral edema that varies with position.

B. Left-sided heart failure

Left-sided failure causes pulmonary symptoms, not systemic peripheral edema. It may eventually lead to right-sided failure, but by itself, it does not directly cause the type of day-dependent leg edema described.

D. COPD

Chronic obstructive pulmonary disease affects the lungs and can lead to cor pulmonale (right heart failure), but COPD alone does not directly cause this positional leg edema pattern.

Summary:

Option C is correct because right-sided heart failure leads to dependent edema that becomes more apparent during the day and improves at night, fitting the pattern described.