ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?
- A. Endocarditis
- B. Multiple myeloma
- C. Guillain-Barr syndrome
- D. Overdose of amphetamines
Correct answer: Guillain-Barr syndrome
Rationale:
2. A client is prescribed diazepam (Valium) for anxiety. Which statement by the client indicates a need for further teaching?
- A. I can drink alcohol while taking this medication.
- B. I should avoid drinking alcohol while taking this medication.
- C. I should take this medication only when I feel anxious.
- D. I can stop taking this medication when I feel better.
Correct answer: A
Rationale: The correct answer is A because clients should avoid alcohol while taking diazepam (Valium) due to potential interactions. Alcohol can increase the sedative effects of diazepam, leading to excessive drowsiness or respiratory depression. Choice B is correct as it reflects the need to avoid alcohol. Choice C is incorrect because diazepam is usually taken regularly, not just when feeling anxious. Choice D is incorrect as abruptly stopping diazepam can lead to withdrawal symptoms and should be done gradually under medical supervision.
3. Evidence-based practice (EBP), a decision-making model, is best described as which?
- A. Using information in textbooks to guide care
- B. Combining knowledge with clinical experience and intuition
- C. Using a professional code of ethics as a means for decision-making
- D. Gathering all evidence that applies to the child’s health and family situation
Correct answer: D
Rationale: Evidence-based practice involves gathering and integrating all relevant evidence to guide clinical decision-making, ensuring that care is based on the best available research.
4. April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:
- A. Time-out is an important part of April's baseline discipline.
- B. Time-out is no longer an effective therapeutic measure.
- C. April enjoys time-out, and acts out to get some alone time.
- D. Time-out will need to be replaced with seclusion and restraint.
Correct answer: B
Rationale: Frequent use of time-out has reduced its effectiveness as a therapeutic measure for April.
5. A healthcare professional is assessing a client receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the healthcare professional identify as an adverse effect of the medication?
- A. Diarrhea.
- B. Urinary retention.
- C. Hypotension.
- D. Bradycardia.
Correct answer: C
Rationale: Hypotension is a common adverse effect of morphine due to its vasodilatory properties. It can lead to a drop in blood pressure, which should be closely monitored during administration. Diarrhea (Choice A) is not a typical adverse effect of morphine. Urinary retention (Choice B) is a side effect of morphine due to its impact on the bladder muscles, but it is not classified as an adverse effect. Bradycardia (Choice D) is not a common adverse effect of morphine; instead, it tends to cause tachycardia.
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