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Ati Advanced Nursing Concept Drake State College Proctored Exam
Total Questions : 51
Showing 10 questions, Sign in for moreA nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?
A nurse is caring for a preschool-age child.
The nurse should determine the assessment findings are consistent with which of the following disease processes? For each assessment finding, click to specify if the assessment finding is consistent with laryngotracheobronchitis (LTB), epiglottitis, or foreign body aspiration. Each finding may support more than 1 disease process.
Explanation
Rationale:
- Immunization status (Epiglottitis): Lack of immunization, particularly against Haemophilus influenzae type b (Hib), is a major risk factor for epiglottitis.
- Respiratory rate (LTB, Epiglottitis, Aspiration): Tachypnea occurs with any condition causing significant upper airway obstruction or respiratory distress.
- Irritability (LTB, Epiglottitis, Aspiration): Children with hypoxia or respiratory compromise commonly become restless and irritable regardless of the underlying cause.
- Fever (LTB, Epiglottitis): Fever is common in infectious airway diseases. Epiglottitis typically presents with a high fever, whereas croup usually causes a low-grade fever.
- Drooling (Epiglottitis, Aspiration): Drooling results from inability to swallow because of upper airway obstruction. It is a classic finding in epiglottitis and may also occur with an upper airway foreign body but is not characteristic of laryngotracheobronchitis.
A nurse is providing care for multiple clients diagnosed with infections. Which of the following clients is at the greatest risk of sepsis?
A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? (Select All that Apply.)
A provider prescribes dextrose 5% in water IV to infuse at 100 mL/hr. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round the answer to the nearest whole number.)
Explanation
Step 1: Identify formula gtt/min = (mL/hr × Drop factor) ÷ 60
Step 2: Insert values = (100 mL/hr × 60 gtt/mL) ÷ 60
Step 3: Calculate = 6000 ÷ 60 = 100 gtt/min
Final Answer: 100 gtt/min
When managing a client who sustained a coup-contrecoup injury, which intervention addresses the most urgent complication associated with increased intracranial pressure?
A nurse is preparing to start an IV infusion of lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Step 1: Identify formula
mL/hr = Volume to infuse ÷ Time (hr)
Step 2: Insert values
First 8 hr volume = 5,200 mL ÷ 2 = 2,600 mL
= 2,600 mL ÷ 8 hr
Step 3: Calculate
= 325 mL/hr
Final Answer: 325 mL/hr
Today, 0700:
Respiratory: Respirations symmetrical and nonlabored, lung sounds clear bilaterally
Cardiovascular: +2 pedal pulses, 51, 52, no murmur, color is consistent with surrounding tissue: facial edema
Genitourinary: Urine dark and smoky, no bladder tenderness
Gastrointestinal: Bowel sounds present x4, abdomen flat and nontender Integumentary: Dry skin
A nurse is assisting with the care of a client in the emergency department.
A nurse is caring for a client who has a traumatic brain injury and is being mechanically ventilated. Which of the following can cause unfavorable outcomes for this client?
A nurse is preparing to administer dextrose 5% in water (DW) 150 mL IV to infuse over 3 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/m in? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Step 1: Identify formula
gtt/min = (mL × Drop factor) ÷ Time (min)
Step 2: Insert values
Time = 3 hr × 60 = 180 min
= (150 mL × 10 gtt/mL) ÷ 180 min
Step 3: Calculate
= 1500 ÷ 180
= 8.33 gtt/min
≈ 8 gtt/min
Final Answer: 8 gtt/min
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