a nurse is administering iv fluids to a dehydrated patient what is the nurses priority assessment
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. When administering IV fluids to a dehydrated patient, what is the nurse's priority assessment?

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. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Avoid lifting more than 10 lb.' After a cataract extraction, the nurse should instruct the client to avoid lifting heavy objects to prevent increased intraocular pressure, which could lead to complications. Choices A, B, and D are incorrect. A - 'Bend at the waist when picking up objects' can increase intraocular pressure; B - 'Avoid lying on the operative side' is not a specific concern related to cataract extraction; D - 'Apply ice to the affected eye' is not a standard post-cataract extraction instruction.

3. A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?

Correct answer: B

Rationale: The correct action for the nurse to take when finding that the TPN solution is infusing too rapidly is to stop the TPN infusion. This is crucial to prevent fluid overload and ensure the client's safety. Sitting the client upright (Choice A) or turning the client on their left side (Choice C) are not appropriate responses to a rapidly infusing TPN solution and do not address the immediate issue of preventing complications from the rapid infusion. Adding insulin to the TPN infusion (Choice D) is not indicated unless specifically prescribed by the healthcare provider for the client's condition. Therefore, the priority action is to stop the TPN infusion to prevent potential harm.

4. In a disaster where a building has collapsed, which victim should a nurse attend to first?

Correct answer: B

Rationale: In a disaster situation like a building collapse, the nurse should attend to the victim with a partial amputation of a leg who is bleeding profusely first. This victim is at immediate risk of severe blood loss, which can be life-threatening. It is crucial to address life-threatening injuries like severe bleeding before attending to other less urgent cases. The victim with the amputation requires immediate intervention to control bleeding and stabilize their condition. Victims who are already deceased or have less urgent injuries can be attended to after addressing the critical cases.

5. What is the most important action for the nurse to take before administering digoxin to a patient?

Correct answer: A

Rationale: The correct answer is to check the patient's heart rate before administering digoxin. Digoxin is a medication that primarily affects cardiac function. Monitoring the heart rate is crucial because digoxin can cause arrhythmias or worsen existing heart rhythm abnormalities. Assessing blood pressure may also be important but is secondary to evaluating the heart rate when administering digoxin. Ensuring the patient has eaten before administration is not directly related to the safe administration of digoxin. Monitoring the patient's weight is not a priority action before administering digoxin.

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