a nurse is assessing a client who is receiving a continuous heparin infusion which of the following findings should the nurse report to the provider
Logo

Nursing Elites

ATI RN

ATI RN Exit Exam Test Bank

1. A nurse is assessing a client who is receiving a continuous heparin infusion. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D because an INR of 1.0 is below the therapeutic range for clients receiving heparin, indicating a potential need for dosage adjustment. Platelet count (choice A) within normal range, aPTT (choice B) within therapeutic range, and hemoglobin level (choice C) are not directly related to the monitoring of heparin therapy and would not require immediate reporting to the provider.

2. A client at 14 weeks gestation reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?

Correct answer: A

Rationale: The correct response is to use open-ended questions that allow the client to explore and express their feelings. Choice A encourages the client to describe their feelings, fostering open communication and providing an opportunity for the client to express themselves freely. Choices B and C do not directly address the client's feelings and may not promote open communication. Choice D focuses on the timing of the feelings rather than exploring the feelings themselves, making it a less therapeutic response.

3. A nurse is planning care for a client who has dehydration. Which of the following interventions should the nurse include?

Correct answer: D

Rationale: The correct intervention for a client with dehydration is to administer 0.45% sodium chloride IV. This solution helps correct fluid imbalance by providing the necessary electrolytes. Restricting fluid intake (Choice A) is not appropriate for dehydration as the client needs adequate fluids to rehydrate. Providing a high-protein diet (Choice B) is not directly related to correcting dehydration. Encouraging the client to ambulate frequently (Choice C) is beneficial for overall health but does not address the issue of dehydration directly.

4. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.0 mEq/L is below the normal range and indicates hypokalemia, which should be reported to the provider. Hypokalemia can lead to serious complications such as cardiac arrhythmias. Choices A, B, and D are within normal ranges and do not require immediate reporting. A blood glucose level of 150 mg/dL is slightly elevated but not critically high. A serum sodium level of 138 mEq/L is within the normal range. A serum albumin level of 3.8 g/dL is also within the normal range.

5. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

Correct answer: C

Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.

Similar Questions

Which electrolyte imbalance is most concerning for a patient on furosemide?
A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the nurse report to the provider?
A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings is a priority for the nurse to report?
A nurse is caring for a client who has a wound infection and is receiving gentamicin. Which of the following laboratory values should the nurse monitor to detect an adverse effect of this medication?
What is the best position for a patient with respiratory distress?

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