ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. A nurse is administering insulin to a patient after misreading their glucose as 210 mg/dL instead of 120 mg/dL. What should the nurse monitor for?
- A. Monitor for hypoglycemia
- B. Monitor for hyperkalemia
- C. Administer glucose IV
- D. Document the incident
Correct answer: A
Rationale: The correct answer is to monitor for hypoglycemia. Insulin administration based on a misread glucose level can lead to hypoglycemia due to the unnecessary lowering of blood sugar levels. Monitoring for hypoglycemia involves assessing the patient's blood glucose levels frequently, observing for signs and symptoms such as shakiness, confusion, sweating, and administering glucose if hypoglycemia occurs. Choice B, monitoring for hyperkalemia, is incorrect as insulin administration typically lowers potassium levels. Choice C, administering glucose IV, is not the immediate action needed as the patient could potentially develop hypoglycemia from the excess insulin. Choice D, documenting the incident, is important but not the immediate priority when dealing with a potential hypoglycemic event.
2. Ceroid pigments and lipofuscin accumulate with aging, impairing a cell's ability to withstand the damaging effects of oxygen free radicals.
- A. True
- B. False
- C. Not Sure
- D. None of the above
Correct answer: True
Rationale: The statement provided in the question is true. Ceroid pigments and lipofuscin are products of cellular damage and aging. These substances accumulate within cells over time and can impair cellular functions, including the ability to withstand the damaging effects of oxygen free radicals. Choice B, 'False,' is incorrect because the accumulation of ceroid pigments and lipofuscin does indeed impair a cell's ability to deal with oxidative stress. Choices C and D are also incorrect as the statement is true.
3. A patient is taking medroxyprogesterone acetate (Provera) for the treatment of endometriosis. What should the nurse teach the patient about this medication?
- A. Medroxyprogesterone should be taken with food to prevent nausea.
- B. Medroxyprogesterone should be taken at the same time each day to maintain consistent hormone levels.
- C. Medroxyprogesterone can be taken intermittently when symptoms worsen.
- D. Medroxyprogesterone should be stopped if side effects occur.
Correct answer: B
Rationale: The correct answer is B. Medroxyprogesterone should be taken at the same time each day to maintain consistent hormone levels and effectiveness. Choice A is incorrect because medroxyprogesterone does not necessarily need to be taken with food. Choice C is incorrect as it is typically prescribed continuously rather than intermittently. Choice D is incorrect because patients should not stop the medication if side effects occur without consulting their healthcare provider.
4. Each of the following is a function of the liver except one. Which one is the exception?
- A. Regulatory control of nutrients in the bloodstream
- B. Conversion of monosaccharides to triglycerides
- C. Breakdown of polysaccharide glycogen into glucose
- D. Oxidation of digestive end products to provide energy
Correct answer: B
Rationale: The correct answer is B. The liver does not convert monosaccharides to triglycerides; instead, it converts monosaccharides to glucose or glycogen. Choice A is correct because the liver plays a role in regulating the levels of various nutrients in the bloodstream. Choice C is correct as the liver breaks down stored glycogen into glucose to maintain blood sugar levels. Choice D is correct as the liver oxidizes digestive end products to provide energy. Therefore, only choice B is incorrect as the liver does not convert monosaccharides to triglycerides.
5. A client in a prenatal clinic is being taught by a nurse in her second trimester with a new diagnosis of gestational diabetes. Which of the following client statements indicates a need for further teaching?
- A. I should limit my carbohydrates to 50% of caloric intake.
- B. I will reduce my exercise schedule to 3 days a week.
- C. I will take my glyburide daily with breakfast.
- D. I know I am at increased risk of developing type 2 diabetes.
Correct answer: I will reduce my exercise schedule to 3 days a week.
Rationale: Choice B, 'I will reduce my exercise schedule to 3 days a week,' indicates a need for further teaching. Regular exercise is beneficial in managing gestational diabetes and should not be reduced without proper guidance. Choices A, C, and D demonstrate understanding and appropriate actions in managing gestational diabetes.
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