ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. . A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
- A. The catheter has been in place for 20 hours.
- B. . The client has poor vascular access in the upper extremities.
- C. The catheter is placed in the proximal tibia.
- D. The clients left lower extremity is cool to the touch.
Correct answer: The clients left lower extremity is cool to the touch.
Rationale:
2. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?
- A. Do you understand that the voices are not real?
- B. Why do you think the voices are talking to you?
- C. Have you tried going to a private place when this occurs?
- D. What helps you ignore what you are hearing?
Correct answer: D
Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.
3. A client with HIV is beginning therapy with zidovudine. The nurse should monitor the client for which of the following adverse effects of this medication?
- A. Fatigue
- B. Blurred vision
- C. Ringing in the ears
- D. Constipation
Correct answer: A
Rationale: Fatigue is a common adverse effect of zidovudine due to its impact on bone marrow, leading to anemia. Zidovudine is known to suppress bone marrow function, resulting in decreased production of red blood cells and subsequently causing fatigue due to anemia. Monitoring for fatigue is essential to ensure early detection and management of this adverse effect.
4. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?
- A. Place the client in seclusion when she is confused.
- B. Request a prescription for PRN restraints when the client is wandering.
- C. Dim the lighting in the client's room.
- D. Leave one side rail up on the client's bed.
Correct answer: C
Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.
5. In Maslow’s hierarchy of physiological needs, the human need of greatest priority is:
- A. Love
- B. Elimination
- C. Nutrition
- D. Oxygen
Correct answer: D
Rationale: In Maslow’s hierarchy of physiological needs, the most basic and immediate need is physiological survival, which includes the need for oxygen. Without oxygen, the body cannot survive for more than a few minutes, making it the highest priority physiological need according to Maslow's hierarchy.
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