for which client situation would a consultation with a rapid response team rrt be most appropriate

ATI RN

ATI RN Custom Exams Set 3

1. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
C. 56-year-old fourth hospital day after a coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization.
D. 86-year-old; 48 hours postoperative repair of a fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter.

Correct answer: A

Rationale: A consultation with a Rapid Response Team (RRT) is most appropriate for the 45-year-old client described in Choice A. This client is 2 years post kidney transplant, presenting with no urine output for 6 hours, a temperature of 101.4°F, heart rate of 98 beats per minute, respirations of 20 breaths per minute, and a blood pressure of 88/72 mm Hg, along with restlessness. These clinical signs are indicative of possible acute renal failure and sepsis, requiring immediate intervention by the rapid response team. Choices B, C, and D do not present the same level of urgency and severity of symptoms as the client in Choice A, making them less appropriate for consultation with the RRT.

2. At the end of the Practical Nurse Course, the student receives a structured review to prepare the student for which of the following?

A. The Army Nurse Course
B. Out-processing
C. The next duty assignment
D. The practical nurse licensure examination

Correct answer: D

Rationale: The structured review at the end of the Practical Nurse Course is specifically designed to prepare students for the practical nurse licensure examination. This examination is crucial for students to obtain their practical nurse license and start their career as a licensed practical nurse. Choices A, B, and C are incorrect because the focus at the end of the course is on preparing students for the licensure examination, not for Army Nurse Course, out-processing, or the next duty assignment.

3. Warfarin (Coumadin) is an anticoagulant and interferes with the action of:

A. Platelets
B. Vitamin K
C. Calcium
D. Vitamin B12

Correct answer: B

Rationale: The correct answer is B: Vitamin K. Warfarin works by inhibiting the action of vitamin K, which is crucial for the synthesis of clotting factors in the blood. By interfering with vitamin K, warfarin decreases the production of these clotting factors, thereby prolonging the time it takes for blood to clot. This is why individuals on warfarin therapy need to monitor their vitamin K intake. Choices A, C, and D are incorrect because warfarin does not directly interfere with platelets, calcium, or vitamin B12.

4. Which electrolyte imbalance is a potential side effect of diuretics?

A. Hyperkalemia
B. Hypercalcemia
C. Hypomagnesemia
D. Hypokalemia

Correct answer: D

Rationale: The correct answer is D, Hypokalemia. Diuretics commonly cause hypokalemia due to increased urinary excretion of potassium. Hyperkalemia (Choice A) is the opposite, characterized by high potassium levels and is not typically associated with diuretics. Hypercalcemia (Choice B) is an elevated calcium level, which is not a common side effect of diuretics. Hypomagnesemia (Choice C) is low magnesium levels, which can be a side effect of diuretics, but the most common electrolyte imbalance associated with diuretics is hypokalemia.

5. An important part of nutrition therapy for patients with cystic fibrosis is:

A. A low-fat diet to prevent steatorrhea
B. A low-sodium diet to normalize fluid status
C. A high-fiber diet to normalize bowel function
D. Pancreatic enzyme replacement therapy to help digestion

Correct answer: D

Rationale: The correct answer is D: Pancreatic enzyme replacement therapy to help digestion. In cystic fibrosis, pancreatic insufficiency leads to the malabsorption of nutrients, making it essential for patients to take pancreatic enzymes to aid in digestion. Options A, B, and C are incorrect because a low-fat diet may not provide adequate nutrition for cystic fibrosis patients, a low-sodium diet is not the primary focus of nutrition therapy in cystic fibrosis, and a high-fiber diet may exacerbate gastrointestinal symptoms due to malabsorption.