ATI Exit Exam 180 Questions Quizlet

Correct Answer: C

Rationale: Jugular vein distention is a classic sign of left-sided heart failure due to fluid overload in the pulmonary circulation. This occurs because the heart's left side is unable to pump effectively, causing increased pressure in the pulmonary veins and leading to blood backing up into the pulmonary circulation. Peripheral edema (choice A) and dependent edema (choice D) are more commonly associated with right-sided heart failure where blood pools in the systemic circulation, causing swelling in the extremities. Bradycardia (choice B) is not typically a direct consequence of left-sided heart failure; instead, tachycardia is more commonly seen as the heart compensates for its reduced efficiency.

Correct Answer: B

Rationale: The correct answer is B. Critical pathways are structured, multi-disciplinary plans of care designed to decrease health care costs and improve outcomes by standardizing and streamlining processes. Choice A is incorrect because critical pathways have specific timeframes for completion. Choice C is incorrect as patients are expected to follow the critical pathway without deviations to achieve optimal outcomes. Choice D is incorrect because budgets do not create critical pathways; rather, they are based on clinical guidelines and best practices.

Correct Answer: A

Rationale: The correct action for the nurse to take when caring for a client with Raynaud's disease is to provide information about stress management. Raynaud's disease is a condition where the blood vessels narrow in response to cold or stress, leading to reduced blood flow to certain areas of the body, usually the fingers and toes. Stress management helps reduce triggers for Raynaud's disease by minimizing emotional stress, which can trigger vasospasms. Choice B is incorrect as maintaining a warm temperature, rather than a cool one, is recommended for individuals with Raynaud's disease to prevent triggering vasospasms. Choice C is incorrect because epinephrine is not typically used to manage Raynaud's disease, as it can further constrict blood vessels. Choice D is incorrect as glucocorticoid steroids are not a first-line treatment for Raynaud's disease.

Correct Answer: D

Rationale: The correct answer is D: Whole milk. Clients with cholecystitis should avoid high-fat foods, and whole milk contains high levels of fat. Bananas, oatmeal, and brown rice are generally considered safe for clients with cholecystitis as they are low in fat and easily digestible. Bananas are a good source of potassium, oatmeal is high in fiber, and brown rice provides complex carbohydrates. Therefore, the nurse should advise the client to avoid whole milk but can recommend the other choices as part of a balanced diet for cholecystitis.

Correct Answer: D

Rationale: The correct answer is to evaluate the client's ability to help with repositioning. When caring for a client who had a stroke, assessing their ability to participate in repositioning is crucial for promoting safety and encouraging their involvement in their care. This evaluation helps determine the level of assistance needed and supports the client's autonomy. Option A is incorrect because raising the side rails alone does not address the client's active involvement in repositioning. Option B is incorrect as using assistive devices may be necessary for safe repositioning. Option C is incorrect as discussing preferences is important but does not directly address the client's ability to assist in repositioning.