ATI Exit Exam 180 Questions Quizlet

Correct Answer: B

Rationale: Shortness of breath is a critical finding that can indicate a pulmonary embolism, a severe complication of DVT. This symptom suggests a potential life-threatening situation and requires immediate intervention. Calf tenderness, while common in DVT, is not as urgent as shortness of breath. Elevated blood pressure and a respiratory rate of 18/min are important to assess but are not typically as indicative of a serious complication like a pulmonary embolism.

Correct Answer: B

Rationale: The correct answer is B: Consume foods high in fiber and low in fat. Following a colon resection and a new colostomy, a high-fiber, low-fat diet is recommended to promote healing and reduce the risk of complications. Foods high in fiber help maintain bowel regularity and prevent constipation, which is crucial after this type of surgery. Choices A, C, and D are incorrect because avoiding foods high in protein, consuming foods high in vitamin C, or avoiding all raw vegetables are not the most appropriate dietary advice in this situation.

Correct Answer: C

Rationale: A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. While a heart rate of 88/min, pain rating of 4, and a temperature of 37.2�C (99�F) are within normal ranges and do not indicate immediate concern related to morphine administration.

Correct Answer: B

Rationale: The correct answer is B: Tachycardia. In hypovolemia, the body responds to decreased fluid volume by increasing the heart rate (tachycardia) to maintain adequate circulation. Bradycardia (Choice A) is not expected in hypovolemia since the heart rate typically increases to compensate for the reduced blood volume. Increased blood pressure (Choice C) is unlikely in hypovolemia as the decreased fluid volume leads to decreased pressure. A bounding pulse (Choice D) is more associated with conditions like hyperthyroidism or fever, not specifically with hypovolemia.

Correct Answer: D

Rationale: In the scenario presented, the correct action for the nurse to take when caring for a client with a verbal prescription for restraints due to acute mania is to document the client's condition every 15 minutes. Documenting at regular intervals is essential to monitor the client's well-being, assess the effects of the restraints, and ensure the client's safety. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse every 30 minutes (Choice B) is important but not as crucial as documenting the overall condition. Obtaining a prescription for restraints within 4 hours (Choice C) is not the immediate action needed when a verbal prescription is already obtained.