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 ha
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Nursing Elites

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?

Correct answer: Guillain-Barr syndrome

Rationale:

2. What is the best intervention for a patient experiencing hypoxia?

Correct answer: A

Rationale: The best intervention for a patient experiencing hypoxia is to administer oxygen. Oxygen therapy helps improve oxygenation levels in the blood, addressing the underlying cause of hypoxia. Repositioning the patient, providing humidified air, and chest physiotherapy may be beneficial in certain situations but are not the primary interventions for hypoxia. Administering oxygen is crucial to quickly alleviate hypoxia and support the patient's respiratory function.

3. What is the function of villi and microvilli in the GI tract?

Correct answer: D

Rationale: Villi and microvilli in the GI tract serve to increase the surface area of the small intestine, aiding in the absorption of nutrients into the bloodstream. Choices A, B, and C are incorrect as villi and microvilli are primarily involved in enhancing absorption, not in producing bile, killing bacteria, or producing vitamin K.

4. A patient with breast cancer is prescribed tamoxifen (Nolvadex). What critical information should the nurse provide during patient education?

Correct answer: A

Rationale: When a patient is prescribed tamoxifen, a critical piece of information that the nurse should provide during patient education is that tamoxifen may increase the risk of venous thromboembolism. Therefore, patients should be educated about the signs and symptoms of blood clots and advised to seek immediate medical attention if they occur. Choice B is incorrect because tamoxifen does not decrease the risk of osteoporosis. Choice C is incorrect as weight gain is a possible side effect of tamoxifen, but it is not a critical piece of information compared to the risk of venous thromboembolism. Choice D is incorrect because tamoxifen is actually used to treat breast cancer, not increase its risk.

5. The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include?

Correct answer: D

Rationale: The correct intervention for the nurse to include in the care plan for a client diagnosed with nephritic syndrome is to instruct the client to report any decrease in daily weight during treatment to the healthcare provider. A decrease in weight could indicate worsening of the nephritic syndrome or dehydration, making it crucial information for the healthcare provider to assess the client's condition. Option A is incorrect because discontinuing steroid therapy should be done under medical guidance rather than immediately if symptoms develop. Option B is incorrect because diuretics should not be taken without healthcare provider's guidance due to the risk of electrolyte imbalances. Option C is incorrect as increasing dietary sodium would exacerbate fluid retention, which is undesirable in nephritic syndrome.

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