a nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration what finding should the nurse intervene f
Logo

Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration. What finding should the nurse intervene for?

Correct answer: B

Rationale: A heart rate of 120 beats per minute indicates tachycardia, which can be a sign of dehydration and requires intervention. A heart rate of 80 beats per minute is within the normal range and does not indicate dehydration. A blood pressure of 110/70 mmHg is considered normal. A respiratory rate of 16 breaths per minute is also within the normal range and does not point towards dehydration.

2. A healthcare professional is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the professional include?

Correct answer: B

Rationale: The correct instruction when using a metered-dose inhaler (MDI) is to shake the inhaler vigorously before use. Shaking the inhaler ensures proper mixing of the medication, which is crucial for effective delivery of the medication into the lungs. Inhaling for a specific duration, holding the inhaler at a certain distance from the mouth, or holding the breath after inhalation are not as critical as ensuring proper mixing of the medication by shaking the inhaler.

3. A nurse is caring for a client who is postoperative following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?

Correct answer: B

Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt the normal bowel movement pattern and lead to constipation. Choices A, C, and D are behaviors that generally help prevent constipation rather than increase the risk. Increased physical activity, adequate sleep, and increased fluid intake promote bowel regularity and reduce the risk of constipation.

4. A nurse is monitoring a client receiving intermittent enteral feedings. What should the nurse identify as a sign of intolerance to the feeding?

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Nausea can indicate various issues such as feeding intolerance, formula composition problems, or underlying medical conditions. Decreased heart rate, fever, and weight gain are not typical signs of feeding intolerance. Decreased heart rate and fever may indicate other medical conditions, while weight gain is not an immediate sign of intolerance to enteral feedings.

5. A client with an indwelling urinary catheter is being cared for by a nurse. What finding indicates a catheter occlusion?

Correct answer: A

Rationale: Bladder distention is the correct answer as it indicates that the catheter is not draining properly, which is a sign of occlusion. Frequent urination, hematuria, and burning sensation are not indicative of a catheter occlusion. Frequent urination may suggest a bladder that is not fully emptying, hematuria indicates blood in the urine, and a burning sensation can be a sign of a urinary tract infection, none of which directly relate to a catheter occlusion.

Similar Questions

A client is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates understanding?
A nurse is preparing to perform an abdominal assessment on a client. Which action should the nurse take first?
A client who is postoperative following abdominal surgery is at risk for constipation due to which behavior?
A nurse is caring for a client who is postoperative following cataract surgery. The client reports that they do not want to wear their eye shield. What should the nurse do?
A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses