ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit
- A. Diarrhea
- B. Dilute urine
- C. Increased muscle tone
- D. Joint pain
Correct answer: Dilute urine
Rationale:
2. Which of the following is not directly related to drug toxicity of Nitroglycerin?
- A. Headaches
- B. Tachycardia
- C. Dizziness
- D. Projectile vomiting
Correct answer: D
Rationale: Headaches, tachycardia, and dizziness are common side effects of nitroglycerin due to its vasodilatory properties. Projectile vomiting is not typically associated with nitroglycerin toxicity, making it the correct answer. Therefore, option D is the correct choice.
3. A client who has a new prescription for alendronate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with a full glass of water before breakfast.
- B. I should take this medication with food to prevent gastrointestinal upset.
- C. I should remain upright for at least 30 minutes after taking this medication.
- D. I should avoid taking this medication with antacids.
Correct answer: C
Rationale: The correct answer is C: "I should remain upright for at least 30 minutes after taking this medication." This statement indicates understanding because clients taking alendronate should remain upright for at least 30 minutes after taking the medication to prevent esophageal irritation. Choice A is incorrect because alendronate should be taken with a full glass of water after waking up, not before breakfast. Choice B is incorrect because alendronate should be taken on an empty stomach, not with food. Choice D is incorrect because alendronate should be taken separately from antacids.
4. A healthcare provider is providing teaching to a client who is starting therapy with paclitaxel. Which of the following adverse effects should the healthcare provider instruct the client to monitor?
- A. Bradycardia
- B. Diarrhea
- C. Neutropenia
- D. Urinary retention
Correct answer: C
Rationale: The correct answer is C: Neutropenia. Paclitaxel commonly causes neutropenia due to bone marrow suppression. It is essential for clients receiving this medication to monitor for signs of neutropenia, such as fever, chills, and increased susceptibility to infections, as it can increase the risk of serious complications.
5. A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching for this client, the nurse should stress:
- A. increasing fluid intake to prevent dehydration.
- B. wearing an appliance pouch at all times.
- C. consuming a low-protein, high-fiber diet.
- D. avoiding enteric-coated medications.
Correct answer: A
Rationale: The correct answer is A: increasing fluid intake to prevent dehydration. An ileostomy typically drains liquid waste, so the client is at risk of fluid loss. By increasing fluid intake, the client can prevent dehydration. It's essential for the client to wear a collection appliance at all times because ileostomy drainage is incontinent. Consuming a low-protein, high-fiber diet is not recommended as high-fiber foods can cause intestinal irritation. Enteric-coated medications should be avoided because they may not be absorbed properly after an ileostomy.
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