ATI RN
ATI Capstone Comprehensive Assessment B
1. When administering IV fluids to a dehydrated patient, what is the nurse's priority assessment?
- A. Monitor the patient's electrolyte levels.
- B. Assess the patient's blood pressure regularly.
- C. Monitor the patient's heart rate every 4 hours.
- D. Check the patient's urine output hourly.
Correct answer: B
Rationale: The correct answer is to assess the patient's blood pressure regularly. Monitoring blood pressure is crucial when administering IV fluids to a dehydrated patient as it helps in evaluating the patient's fluid status. Changes in blood pressure can indicate the effectiveness of the fluid therapy, the patient's response to treatment, and the possibility of complications such as fluid overload or hypovolemia. Monitoring electrolyte levels (Choice A) is essential but not the priority when assessing a dehydrated patient receiving IV fluids. Heart rate (Choice C) should be monitored more frequently than every 4 hours in such a situation. Checking urine output (Choice D) is important but not as critical as assessing blood pressure in this scenario.
2. Which lab test is used to assess renal function?
- A. Check blood glucose levels
- B. Monitor serum creatinine
- C. Monitor BUN
- D. Check electrolyte levels
Correct answer: B
Rationale: The correct answer is B: Monitor serum creatinine. Serum creatinine is a key indicator of renal function as it reflects the glomerular filtration rate. An increase in serum creatinine levels indicates impaired kidney function. Checking blood glucose levels (choice A) is not specific to assessing renal function but is used to diagnose diabetes. Monitoring BUN (choice C) is important but not as specific as serum creatinine in assessing renal function. Checking electrolyte levels (choice D) is essential in assessing kidney function but is not as specific as monitoring serum creatinine.
3. The principal cation in plasma and interstitial fluid is:
- A. Sodium
- B. Potassium
- C. Calcium
- D. Magnesium
Correct answer: A
Rationale: The principal cation in plasma and interstitial fluid is sodium. Sodium plays a crucial role in maintaining fluid balance and is the primary cation in extracellular fluids like plasma and interstitial fluid. Potassium is the primary cation within cells, not in extracellular fluids, making it an incorrect choice. Calcium and magnesium are essential minerals but are not the principal cations in plasma and interstitial fluid, so they are also incorrect choices.
4. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?
- A. Retake the temperature in 15 minutes after giving the Tylenol.
- B. Place a warm blanket on the child so chilling does not occur.
- C. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
- D. Use cold compresses instead of Tylenol to control the fever.
Correct answer: C
Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.
5. A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
- A. "I can concentrate best in the morning."
- B. "It is difficult to read the instructions because my glasses are at home."
- C. "I'm wondering why I need to learn this."
- D. "You will have to talk to my partner about this."
Correct answer: D
Rationale: The correct answer is D, "You will have to talk to my partner about this." This response indicates that the client is willing to involve their partner in the learning process, showing readiness to take responsibility and engage in the education. Choices A, B, and C demonstrate potential barriers to learning: A indicates a preference for learning time but does not show active involvement, B focuses on external factors hindering learning, and C reflects a lack of understanding or motivation for the learning.
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