ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.)
- A. Use a draw sheet to reposition the client in bed.
- B. . Strain all urine output and assess for urinary stones.
- C. Provide nonslip footwear for the client to use when out of bed.
- D.
Correct answer: . Strain all urine output and assess for urinary stones.
Rationale:
2. Which enzyme initiates protein digestion in the stomach?
- A. Pepsin
- B. Salivary Amylase
- C. CCK
- D. Secretin
Correct answer: A
Rationale: Pepsin is the enzyme that initiates protein digestion in the stomach. It breaks down proteins into smaller peptides, aiding in their further digestion and absorption in the intestines. Salivary Amylase (Choice B) functions in breaking down dietary carbohydrates in the mouth, not proteins. CCK (Choice C) and Secretin (Choice D) are hormones involved in the digestion of fats and carbohydrates, not proteins. Therefore, Choices B, C, and D are incorrect in the context of protein digestion in the stomach.
3. A nurse is caring for a client who has a wound infection and is receiving gentamicin. Which of the following laboratory values should the nurse monitor to detect an adverse effect of this medication?
- A. Creatinine.
- B. Aspartate aminotransferase (AST).
- C. White blood cell count.
- D. Serum glucose.
Correct answer: A
Rationale: The correct answer is A: Creatinine. Gentamicin can cause nephrotoxicity, leading to impaired kidney function. Monitoring creatinine levels helps the nurse detect any potential kidney damage. Choice B, Aspartate aminotransferase (AST), is not typically affected by gentamicin. Choice C, White blood cell count, is not directly related to gentamicin adverse effects. Choice D, Serum glucose, is not specifically monitored for gentamicin adverse effects.
4. Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select one that does not apply.
- A. Hold his medication and contact his prescriber.
- B. Wipe him with a washcloth wet with cold water or alcohol.
- C. Administer a medication such as benztropine IM to correct this dystonic reaction.
- D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.
Correct answer: C
Rationale: The patient's symptoms, including stiffness, diaphoresis, inability to respond verbally, and vital sign abnormalities, are indicative of neuroleptic malignant syndrome (NMS), a serious and potentially life-threatening side effect of antipsychotic medications. Administering a medication such as benztropine intramuscularly is the priority to address the dystonic reaction associated with NMS. This intervention can help alleviate symptoms and prevent further complications. Holding the medication and contacting the prescriber may be necessary but addressing the acute symptoms takes precedence. Wiping the patient with a cold washcloth or alcohol would not address the underlying medical emergency. Reassuring the patient about tardive dyskinesia is irrelevant and not the immediate concern in this scenario.
5. A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample?
- A. Perform a new venipuncture to obtain the blood sample.
- B. Interrupt the IV fluid and withdraw the blood sample needed.
- C. Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed.
- D. Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample.
Correct answer: C
Rationale: Withdrawing and discarding a sample equal to the amount of fluid in the device ensures that the blood drawn is not diluted by the IV fluids, providing accurate lab results.
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