Question

ati fundamental test 2024 (nursing process)
72.a nurse is preparing to measure a clients oxygen saturation and notes edema of the clients hands and thickened toenails. the nurse should apply the pulse oximeter probe to which of the following locations?
a. finger
b. earlobe
c. toe
d. skin fold
73.a nurse is collecting data from a client who is receiving intermittent enteral feedings. which of the following laboratory values should the nurse identify as an indication that the client needs a change in the formula?
a. hematocrit 42%
b. urine specific gravity 1.022
c. bun 28 mg/dl
d. sodium 142 meq/l
74.a nurse is completing a clients history and physical examination. which information should the nurse consider subjective data?
a. blood pressure
b. cyanosis
c. nausea
d. petechiae
75.a nurse is collecting data from a client who has isotonic fluid - volume deficit. which of the following findings should the nurse expect?
a. weak pulse
b. bradycardia
c. hypertension
d. distended neck veins

Explanation:

• Question 72: When a client has edema of the hands (so finger - option A is not ideal as edema can interfere) and thickened toenails (so toe - option C is not good), the earlobe (option B) is a suitable alternative site for pulse oximeter probe application. Skin fold (option D) is not a standard site for pulse oximetry.
• Question 73: BUN (blood - urea - nitrogen) is related to protein metabolism and hydration status in the context of enteral feedings. A BUN of 28 mg/dL (option C) may indicate dehydration or an issue with the enteral formula (e.g., too high protein load). Hematocrit 42% (option A) is within normal range (male: 40 - 54%, female: 36 - 48%), urine specific gravity 1.022 (option B) is within normal range (1.005 - 1.030), and sodium 142 mEq/L (option D) is within normal range (135 - 145 mEq/L).
• Question 74: Subjective data is what the client reports. Nausea (option C) is a subjective symptom. Blood pressure (option A), cyanosis (option B), and petechiae (option D) are objective data (can be measured or observed).
• Question 75: In isotonic fluid - volume deficit, the body tries to compensate. A weak pulse (option A) is expected as there is less fluid volume, so the heart has to work harder with less filling. Bradycardia (option B) is not typical (tachycardia is more common in fluid deficit as the heart tries to maintain cardiac output). Hypertension (option C) is not expected (hypotension is more likely). Distended neck veins (option D) are seen in fluid overload, not deficit.

Answer:

1. B. Earlobe
2. C. BUN 28 mg/dL
3. C. Nausea
4. A. Weak pulse