a nurse is caring for a client with a history of renal failure which of the following should the nurse monitor
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN

1. A client with a history of renal failure is being cared for by a nurse. Which of the following should the nurse monitor?

Correct answer: D

Rationale: Clients with renal failure are at risk for electrolyte imbalances and hypertension. Monitoring electrolyte levels is crucial because renal failure can lead to imbalances in sodium, potassium, and other electrolytes. Blood pressure monitoring is essential as hypertension is a common complication of renal failure. Therefore, both electrolyte levels and blood pressure should be closely monitored to detect and manage any abnormalities. Fluid intake, while important, is not specific to renal failure monitoring and is not the priority in this case.

2. A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings. When a client experiences nausea, it can indicate difficulty in tolerating the feeding formula. This intolerance may also manifest as vomiting and dumping syndrome. Choices A, C, and D are incorrect because increased appetite, weight gain, and regular bowel movements are not typical signs of intolerance to enteral feedings.

3. A nurse is assessing a client with pancreatitis. Which of the following findings should the nurse look for?

Correct answer: B

Rationale: The correct answer is B: Abdominal pain. Abdominal pain, often severe, is a hallmark sign of pancreatitis. Other common symptoms include nausea, vomiting, and tenderness in the abdomen. Choices A, C, and D are incorrect because increased appetite, weight gain, and elevated blood pressure are not typically associated with pancreatitis. Therefore, the nurse should primarily focus on assessing for abdominal pain in a client with suspected pancreatitis.

4. A nurse is caring for a client with a history of heroin use who is intoxicated. Which finding should the nurse expect?

Correct answer: A

Rationale: The correct answer is A: Constricted pupils. Constricted pupils are a classic sign of opioid intoxication, including heroin. Opioids like heroin cause the pupils to constrict due to their effect on the autonomic nervous system. Dilated pupils, increased reflexes, and elevated blood pressure are not typically associated with opioid intoxication but may be seen with other substances or conditions.

5. A healthcare provider is reviewing the laboratory data of a client with diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management?

Correct answer: B

Rationale: The correct answer is B: Glycosylated hemoglobin (HbA1c). The glycosylated hemoglobin test measures average blood glucose levels over the past 2-3 months, providing an indication of long-term glycemic control in clients with diabetes. Choice A, postprandial blood glucose, reflects blood sugar levels after a meal and does not provide a long-term view. Choice C, glucose tolerance test, evaluates the body's ability to process sugar but does not offer a continuous assessment like the HbA1c test. Choice D, fasting blood glucose, measures blood sugar levels after a period of fasting, which is more indicative of immediate glycemic status rather than long-term management.

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