ATI HESI Practice Fall 2019 Detailed Answer Key

1. A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? A. Initiate a low-residue diet. Rationale: One of the manifestations of acute pancreatitis is abdominal pain. The nurse should anticipate the provider will prescribe withholding of foods and fluids. This serves to manage the client's pain by limiting gastrointestinal activity and stimulation of the pancreas. B. Pantoprazole 80 mg IV bolus twice daily Rationale: The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions. C. Ambulate twice daily. Rationale: The nurse should anticipate a provider prescription for bed rest during the acute stage of pancreatitis. Bed rest decreases the metabolic rate and the secretion of pancreatic enzymes. D. Pancrelipase 500 units/kg PO three times daily with meals Rationale: The nurse should identify that pancrelipase, an enzyme replacement medication, is used in the treatment of clients who have chronic pancreatitis. It is not used in the treatment of acute pancreatitis. 2. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with air exhaust directly to the outdoor environment Rationale: A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room. B. A room with another nonsurgical client Rationale: A two-bed room with another nonsurgical client exposes the other client to tuberculosis. A client who has tuberculosis should have a private room. C. A room in the ICU Rationale: A client who has active tuberculosis and no other comorbidities is not critically ill. D. A room that is within view of the nurses' station Rationale: The client's room should be well ventilated and private, but it is not necessary for it to be close to the nurses' station. 3. A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor? A. Hypocalcemia Rationale: Hypercalcemia is a risk factor associated with urolithiasis. B. BMI less than 25 Rationale: Obesity, or having a BMI that is greater than 29, has been found to be a risk factor for the development of urolithiasis. C. Family history Rationale: Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a client who has kidney stones for familial tendencies toward stone formation. D. Diuretic use Rationale: Medications such as antacids, vitamin D, laxatives, and aspirin have been associated with the formation of urolithiasis. However, there is no indication that the use of diuretics place a client at an increased risk for stone formation. 4. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature Rationale: Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid.Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid.Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs.Increased hematocrit is incorrect. The nurse should expect the client who has fluid volume deficit to have an elevated hematocrit because of hemoconcentration.Increase temperature is incorrect. The nurse should expect the client who has fluid volume deficit to have an increase in temperature due to fluid loss. 5. A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? A. Lower the height of the solution container. Rationale: If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping has passed. B. Encourage the client to bear down. Rationale: Bearing down will cause early release of the fluid, decreasing the effectiveness of the enema. C. Allow the client to expel some fluid before continuing. Rationale: Allowing the client to expel solution too early in the procedure will decrease the effectiveness of the enema. D. Stop the enema and document that the client did not tolerate the procedure. Rationale: Cramping is a normal response to an enema. There are actions the nurse can take to decrease the cramping. 6. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) A. Dyspnea B. Bradycardia C. Barrel chest D. Clubbing of the fingers E. Deep respirations Rationale: Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back. Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations become increasingly shallow. 7. A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? A. Blood pressure 102/66 mm Hg Rationale: The nurse should identify this finding as within the expected reference range. B. Straw-colored urine from an indwelling urinary catheter Rationale: Straw-colored urine is an expected finding. More information is needed to determine whether to take action in this case. C. Yellow-green drainage on the surgical incision Rationale: Thick yellow-green drainage is indicative of an infection and should be reported immediately. D. Respiratory rate 18/min Rationale: The nurse should identify this finding as within the expected reference range. 8. A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A. analgesic Rationale: Although aspirin does have an analgesic effect, cardiac clients who take 325 mg daily are taking it for a different purpose. B. anti-inflammatory Rationale: Although aspirin does have an analgesic effect, cardiac clients who take 325 mg daily are taking it for a different purpose. C. antiplatelet aggregate Rationale: Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart. D. antipyretic Rationale: Although aspirin does have an antipyretic effect, cardiac clients who take 325 mg daily are taking it for a different purpose. 9. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? A. NPH insulin Rationale: Isophane NPH insulin is intermediate-acting. It has an onset of action of 1 to 3 hr and is not appropriate for emergency treatment of ketoacidosis. B. Insulin glargine Rationale: Insulin glargine is a long-acting insulin, with an onset of 2 to 4 hr. It is not appropriate for emergency treatment of ketoacidosis. C. Insulin detemir Rationale: Insulin detemir is an intermediate-acting insulin. It has an onset of action of 1 hr and is not appropriate for emergency treatment of ketoacidosis. D. Regular insulin Rationale: Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset of action of less than 30 min. This is the insulin that is most appropriate in emergency situations of severe hyperglycemia or diabetic ketoacidosis. 10. A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to read following a stroke would have involvement of the left hemisphere. B. Inability to recognize his family members Rationale: The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere. C. Right hemiparesis Rationale: The motor nerve fibers of the brain cross in the medulla, and a motor deficit on one side of the body reflects damage to the upper motor neurons on the opposite side of the brain. A client who has right hemiparesis would have involvement of the left hemisphere. D. Aphasia Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to speak or understand language following a stroke would have involvement of the left hemisphere.