ATI Exam #1 (Med Surg.) 2024

ATI Exam #1 (Med Surg.) 2024 A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specific gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select all that apply.) A. Decreased skin turgor B. Concentrated urine C. Bradycardia D. Low-grade fever E. Tachypnea A. CORRECT: Decreased skin turgor is a clinical manifestation present with fluid volume deficit. Skin turgor is decreased to due to the lack of fluid within the body and results in dryness of the skin. B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume deficit. The urine is concentrated due to urinary output being decreased. D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume deficit. Low-grade fever is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body. E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit. Increased respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body. A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative of fluid volume excess? (Select all that apply.) A. Dyspnea B. Edema C. Bradycardia D. Hypertension E. Weakness A. CORRECT: Dyspnea is a clinical manifestation present with fluid volume excess. Dyspnea is due to an excess of fluids within the body and lungs, and the client is struggling to breath to obtain oxygen. B. CORRECT: Edema is a clinical manifestation present with fluid volume excess. Edema is due to the excess of fluid within the body. Weight gain can be a result of edema. D. CORRECT: Hypertension is a clinical manifestation related to fluid volume excess. Blood pressure rises as the heart must work harder due to the excess fluid. E. CORRECT: Weakness is a clinical manifestation present with fluid volume excess. Weakness is due to the excess fluid that is retained, which depletes energy and increases the workload for the body. Brainpower Read More Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:06 / 0:15 Full screen A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit? A. Moist skin B. Distended neck veins C. Increased urinary output D. Tachycardia D. CORRECT: Tachycardia is an attempt to maintain blood pressure, a clinical manifestation indicative of fluid volume deficit. A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's temperature is 38.3° C (100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take? A. Initiate fluid restrictions to limit intake. B. Observe for signs of hypertension. C. Encourage the client to ambulate to promote oxygenation. D. Monitor respirations for shortness of breath. D. CORRECT: It is an appropriate action for the nurse to monitor the client's respiratory status and for shortness of breath. The client has a nonproductive cough with diminished breath sounds in the right lower lobe. This client is dehydrated and has fluid volume deficit.