a nurse is assessing a client who is experiencing auditory hallucinations what question should the nurse ask
Logo

Nursing Elites

ATI RN

ATI Exit Exam 2023 Quizlet

1. A nurse is assessing a client who is experiencing auditory hallucinations. What question should the nurse ask?

Correct answer: D

Rationale: Exploring strategies to ignore the hallucinations can help clients manage symptoms.

2. How should fluid balance be assessed in a patient with heart failure?

Correct answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.

3. A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: Dependent edema is a common finding in clients with pneumonia due to fluid retention and decreased mobility. Bradycardia (Choice A) is not typically associated with pneumonia. Crackles in the lung bases (Choice B) are more commonly heard in conditions like heart failure or pulmonary edema. A productive cough (Choice D) can be seen in pneumonia but is not as specific as dependent edema.

4. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse about insulin administration. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is to rotate injection sites within the same region to prevent tissue damage. By rotating sites, the client can prevent lipodystrophy, which is a condition characterized by the loss or change in body fat at the site of repeated injections. This practice also helps to ensure proper insulin absorption. Storing unopened vials of insulin in the refrigerator (Choice A) is correct, not in the freezer, as freezing can damage the insulin. Administering insulin at a 90-degree angle (Choice C) is more appropriate for subcutaneous injections, while a 45-degree angle is used for intramuscular injections. Massaging the injection site after administering insulin (Choice D) is not recommended as it can affect insulin absorption rates.

5. A nurse is assessing a client who is 4 hours postoperative following a total hip arthroplasty. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.

Similar Questions

A nurse is teaching a prenatal class about infection prevention. Which of the following statements indicates an understanding of the teaching?
A healthcare provider is educating a client with type 2 diabetes mellitus about managing blood glucose levels. Which of the following statements by the client indicates a need for further teaching?
Which lab value is most critical to monitor in a patient receiving insulin therapy?
A nurse is teaching a newly licensed nurse about using a portable oxygen system. What instruction should the nurse include?
A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the healthcare professional take first?

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