the nurse observes that a client has received 250 ml of 09 normal saline through the iv line in the last hour the client is now tachypneic and has a p
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ATI LPN

ATI Medical Surgical Proctored Exam 2019 Quizlet

1. The client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?

Correct answer: B

Rationale: In this scenario, the client is showing signs of fluid overload with tachypnea and a high pulse rate. Decreasing the saline to a keep-open rate is appropriate to prevent further fluid volume excess. This action allows for IV access to be maintained while reducing the fluid administered, helping to manage the symptoms of fluid overload.

2. A 45-year-old woman with occasional indigestion has had episodes of chest pain and dysphagia to both solids and liquids. An upper GI series and EGD fail to disclose any structural abnormalities. What is the most appropriate initial therapy?

Correct answer: B

Rationale: The patient's symptoms of chest pain and dysphagia suggest esophageal spasm, often related to underlying gastroesophageal reflux. The initial therapy should focus on acid suppression. Proton pump inhibitors are the preferred choice to reduce acid production and alleviate symptoms. If proton pump inhibitors are ineffective, other options like smooth muscle relaxants or antidepressants may be considered. A Heller myotomy is not indicated in this case as the patient does not have achalasia.

3. The healthcare provider is preparing to administer a blood transfusion. Which action is most important to ensure client safety?

Correct answer: B

Rationale: Verifying the client's identity and blood compatibility is the most critical step in ensuring client safety during a blood transfusion. This process helps prevent transfusion reactions by confirming that the correct blood product is being administered to the right patient.

4. A client who is acutely ill has vigilant oral care included in their plan of care. What factor increases this client's risk for dental caries?

Correct answer: D

Rationale: Inadequate nutrition and decreased saliva production can lead to a conducive environment for the development of dental caries. Without proper nutrition and sufficient saliva, the protective mechanisms against cavities are compromised, making the individual more susceptible to tooth decay.

5. The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?

Correct answer: B

Rationale: Clients with myasthenia gravis commonly experience muscle weakness, including in the muscles used for coughing. This diminished cough effort can lead to ineffective airway clearance, increasing the risk of respiratory complications. Therefore, the most likely cause for the nursing diagnosis 'High risk for ineffective airway clearance' in a client with myasthenia gravis is the diminished cough effort due to muscle weakness.

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