ATI Fundamentals Test Exam 11 2024

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? Increase in hematocrit increase in respiratory rate Decrease in heart rate Decrease in capillary refill time - Correct Answer: Decrease in heart rate Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. Incorrect Answers: Increase in hematocrit: Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular fluid. With correction of the imbalance, the hematocrit level should decrease. increase in respiratory rate Fluid volume deficit causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range. Decrease in capillary refill time Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range. A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate? "The transfer of your family member is being done because the provider knows what's best." "Would you like it if we discussed the transfer with your family member?" "Why are you so concerned about this transfer?" "I know how you feel. My parent had to be transferred to a long-term care facility." - Correct Answer: "Would you like it if we discussed the transfer with your family member?" This response facilitates therapeutic communication and provides general leads while maintaining client confidentiality. Incorrect Answers: "The transfer of your family member is being done because the provider knows what's best." This is a defensive response which can hinder further communication. "Why are you so concerned about this transfer?" Asking a why question can make the recipient defensive which can hinder further communication. "I know how you feel. My parent had to be transferred to a long-term care facility." This is a sympathetic response, which can interfere with a therapeutic relationship. A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurse report to the provider? BUN 21 mg/dL (10 to 20 mg/dL) Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL) Sodium 132 mEq/L (136 to 145 mEq/L) Potassium 5.8 mEq/L (3.5 to 5 mEq/L) - Correct Answer: Potassium 5.8 mEq/L (3.5 to 5 mEq/L) When using the urgent versus nonurgent approach to client care, the nurse should determine that this potassium level is above the expected reference range and should be reported to the provider. Potassium affects the contractility of the heart and this client would be at risk for developing dysrhythmias. Incorrect answers: BUN 21 mg/dL (10 to 20 mg/dL) This BUN level is slightly above the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a priority for the nurse to report to the provider. Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL) This creatinine level is slightly above the expected reference range and is an expected nonurgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a a priority for the nurse to report to the provider. Sodium 132 mEq/L (136 to 145 mEq/L) This sodium level is slightly below the expected reference range and is an expected nonurgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a priority for the nurse to report to the provider. A nurse is caring for a client who reports difficulty falling asleep. Wh