ATI RN Concept -Based Assessment Level 3 B Proctored Exam Questions and Answers with Complete Solutions 100% C orrect A nurse is caring for a client who has gastroenteritis and reports diarrhea and vomiting for 3 days. Which of the following findings should the nurse recognize as a manifestation of this inflammatory bowel disease? -Hiccups -Rebound tenderness of abdomen -Orthostatic hypotension -Shoulder pain - Answer Orthostatic hypotension (The nurse should identify that a client who has gastroenteritis can exhibit orthostatic hypotension caused by dehydration from fluid loss and electrolyte imbalance) -Hiccups (The nurse should identify that a client who has peritonitis can exhibit hiccups caused by inflammation of the diaphragm.) -Rebound tenderness of abdomen (The nurse should identify that a client who has peritonitis can exhibit rebound tenderness of the abdomen.) -Shoulder pain (The nurse should identify that a client who has peritonitis can exhibit referred shoulder or chest pain.) A nurse is reviewing the medical record of a 9 -month -old infant. Which of the following findings should the nurse report to the provider? -WBC count -Hert rate -Gross motor skills -Respiratory rate - Answer Gross motor skills (The nurse should identify that the infant's gross motor skills indicate a possible developmental delay. A 9 -month -
old infant should be able to sit unsupported for up to 10 min at a time.)Res -WBC count (The nurse should identify that a WBC count of 12,000/mm3 is within the expected reference range for a 9 -month -old infant.) -Heart rate (The nurse should identify that a heart rate of 110/min is within the expected reference range for a 9 -month -old infant. -Respiratory rate (The nurse should identify that a respiratory rate of 28/min is within the expected reference range for a 9 -month -old infant.) A nurse is teaching a client who has chronic pain about biofeedback. Which of the following information should the nurse include about this complementary therapy? -Biofeedback provides audio and visual signals to induce a physiological change. -Biofeedback involves manipulating soft tissue to increase circulation. -Biofeedback uses a variety of body movements to strengthen muscles. -Biofeedback uses digital pressure to reduce pain and improve function. - Answer Biofeedback provides audio and visual signals to induce a physiological change. (Biofeedback is a technique that uses audio and visual signals that allow clients to reduce muscle tension by gaining control over autonomic physiological functions.) -Biofeedback involves manipulating soft tissue to increase circulation. (Massage therapy involves manipulating soft tissue to increase circulation and induce muscle relaxation.) -Biofeedback uses a variety of body movements to strengthen muscles. (Yoga and Pilates use a variety of body movements and poses to strengthen core muscles and improve control of muscle groups. -Biofeedback uses digital pressure to reduce pain and improve function. (Acupuncture uses digital pressure on specific areas of the body to reduce pain and improve function.) A nurse is preparing to administer phenytoin via intermittent IV bolus to a client who is having a tonic -clonic seizure caused by epilepsy. Which of the following factors should the nurse consider when administering IV phenytoin? -Mix the phenytoin with 5% dextrose in water. -Discard phenytoin in precipitate occurs when refrigerated. -Administer phenytoin at a rate no greater than 50 mg/min. -Monitor for hypertension while infusing the phenytoin. - Answer Administer phenytoin at a rate no greater than 50 mg/min.(The nurse should administer phenytoin intermittent IV bolus at a rate of no greater than 50 mg/min to prevent the client from developing hypotension and bradycardia.)
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