ATI Lewis: Medical-Surgical Nursing~Chapter 17//
ATI LEWIS COMPREHENSIVE EXIT EXAM RETAKE
2023- 2024 WITH NGN QUESTIONS (ACTUAL EXAM)
The nurse has administered 3% saline to a patient with hyponatremia. Which one of
these assessment data will require the most rapid response by the nurse?
a. The patients radial pulse is 105 beats/minute.
b. There is sediment and blood in the patients urine.
c. The blood pressure increases from 120/80 to 142/94.
d. There are crackles audible throughout both lung fields. - ✔✔ANSWER✔✔>>Answer:
d. There are crackles audible throughout both lung fields.
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary
edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse
rate and blood pressure and the appearance of the urine also should be reported, but
they are not as dangerous as the presence of fluid in the alveoli.
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid,
deep respirations. Which action should the nurse take?
a. Notify the patient's health care provider.
b. Give the prescribed PRN lorazepam (Ativan).
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Encourage the patient to take deep, slow breaths. - ✔✔ANSWER✔✔>>Answer: a.
Notify the patient's health care provider.
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for
actions such as administration of sodium bicarbonate, which will require a prescription
by the health care provider. Oxygen therapy is not indicated because there is no
indication that the increased respiratory rate is related to hypoxemia. The respiratory
pattern is compensatory, and the patient will not be able to slow the respiratory rate.
Ativan administration will slow the respiratory rate and increase the level of acidosis.
The nurse obtains all of the following assessment data about a patient with deficient
fluid volume caused by a massive burn injury. Which of the following assessment data
will be of greatest concern?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
, d. There is prolonged skin tenting over the sternum. - ✔✔ANSWER✔✔>>Answer: a.
The blood pressure is 90/40 mm Hg.
The blood pressure indicates that the patient may be developing hypovolemic shock as
a result of fluid loss. This will require immediate intervention to prevent the
complications associated with systemic hypoperfusion. The poor oral intake, decreased
urine output, and skin tenting all indicate the need for increasing the patients fluid intake
but not as urgently as the hypotension.
When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority
assessment for the nurse to obtain is:
a. skin turgor.
b. heart sounds.
c. mental status.
d. capillary refill. - ✔✔ANSWER✔✔>>Answer: c. mental status.
Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous
system, initially causing confusion, which may progress to coma or seizures. Although
skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality
changes and resultant fluid shifts, these are signs that occur later and do not have as
immediate an impact on patient outcomes.
When caring for a patient admitted with hyponatremia, which actions will the nurse
anticipate taking?
a. Restrict patient's oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solution of 5% dextrose in a 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, [ADH]). - ✔✔ANSWER✔✔>>Answer:
a. Restrict patient's oral free water intake.
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
beverages will improve the patients sodium level. Administration of vasopressin or
hypotonic IV solutions will decrease the serum sodium level further.
When caring for an alert and oriented elderly patient with a history of dehydration, the
home health nurse will teach the patient to increase fluid intake:
a. in the late evening hours.
b. if the oral mucosa feels dry.
c. when the patient feels thirsty.
d. as soon as changes in level of consciousness (LOC) occur. -
✔✔ANSWER✔✔>>Answer: b. if the oral mucosa feels dry.
ATI LEWIS COMPREHENSIVE EXIT EXAM RETAKE
2023- 2024 WITH NGN QUESTIONS (ACTUAL EXAM)
The nurse has administered 3% saline to a patient with hyponatremia. Which one of
these assessment data will require the most rapid response by the nurse?
a. The patients radial pulse is 105 beats/minute.
b. There is sediment and blood in the patients urine.
c. The blood pressure increases from 120/80 to 142/94.
d. There are crackles audible throughout both lung fields. - ✔✔ANSWER✔✔>>Answer:
d. There are crackles audible throughout both lung fields.
Crackles throughout both lungs suggest that the patient may be experiencing pulmonary
edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse
rate and blood pressure and the appearance of the urine also should be reported, but
they are not as dangerous as the presence of fluid in the alveoli.
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid,
deep respirations. Which action should the nurse take?
a. Notify the patient's health care provider.
b. Give the prescribed PRN lorazepam (Ativan).
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Encourage the patient to take deep, slow breaths. - ✔✔ANSWER✔✔>>Answer: a.
Notify the patient's health care provider.
The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for
actions such as administration of sodium bicarbonate, which will require a prescription
by the health care provider. Oxygen therapy is not indicated because there is no
indication that the increased respiratory rate is related to hypoxemia. The respiratory
pattern is compensatory, and the patient will not be able to slow the respiratory rate.
Ativan administration will slow the respiratory rate and increase the level of acidosis.
The nurse obtains all of the following assessment data about a patient with deficient
fluid volume caused by a massive burn injury. Which of the following assessment data
will be of greatest concern?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
, d. There is prolonged skin tenting over the sternum. - ✔✔ANSWER✔✔>>Answer: a.
The blood pressure is 90/40 mm Hg.
The blood pressure indicates that the patient may be developing hypovolemic shock as
a result of fluid loss. This will require immediate intervention to prevent the
complications associated with systemic hypoperfusion. The poor oral intake, decreased
urine output, and skin tenting all indicate the need for increasing the patients fluid intake
but not as urgently as the hypotension.
When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority
assessment for the nurse to obtain is:
a. skin turgor.
b. heart sounds.
c. mental status.
d. capillary refill. - ✔✔ANSWER✔✔>>Answer: c. mental status.
Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous
system, initially causing confusion, which may progress to coma or seizures. Although
skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality
changes and resultant fluid shifts, these are signs that occur later and do not have as
immediate an impact on patient outcomes.
When caring for a patient admitted with hyponatremia, which actions will the nurse
anticipate taking?
a. Restrict patient's oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solution of 5% dextrose in a 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, [ADH]). - ✔✔ANSWER✔✔>>Answer:
a. Restrict patient's oral free water intake.
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
beverages will improve the patients sodium level. Administration of vasopressin or
hypotonic IV solutions will decrease the serum sodium level further.
When caring for an alert and oriented elderly patient with a history of dehydration, the
home health nurse will teach the patient to increase fluid intake:
a. in the late evening hours.
b. if the oral mucosa feels dry.
c. when the patient feels thirsty.
d. as soon as changes in level of consciousness (LOC) occur. -
✔✔ANSWER✔✔>>Answer: b. if the oral mucosa feels dry.
