ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
- A. Choose a hairless site if available.
- B. Consider potential effects on the patients mobility when selecting a site.
- C. Have the patient briefly hold his arm over his head before insertion
- D. Leave the tourniquet on for at least 3 minutes.
Correct answer: Consider potential effects on the patients mobility when selecting a site.
Rationale:
2. A patient is being treated with finasteride (Proscar) for benign prostatic hyperplasia (BPH). What expected outcome should the nurse include in the patient teaching?
- A. The medication will cure BPH after treatment is complete.
- B. The effects of the medication may take several weeks or months to become noticeable.
- C. The medication may cause increased hair growth.
- D. The medication may decrease libido.
Correct answer: B
Rationale: The correct answer is B. Finasteride is used to reduce the size of the prostate gland in patients with BPH, leading to decreased urinary frequency and urgency over several weeks or months. Choice A is incorrect because finasteride does not cure BPH but helps manage symptoms. Choice C is incorrect as increased hair growth is associated with another medication called minoxidil, not finasteride. Choice D is incorrect since finasteride may cause a decrease in libido as a side effect.
3. A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
- A. Auscultate the apical pulse and count for 1 minute
- B. Place a sensor on the index finger
- C. Heat the skin prior to placing the probe
- D. Recheck after 10 minutes
Correct answer: A
Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.
4. _____ neutralizes stomach acid in the small intestine:
- A. saliva
- B. gastric mucus
- C. bicarbonate ions
- D. enzymes
Correct answer: C
Rationale: The correct answer is C: bicarbonate ions. Bicarbonate ions, secreted by the pancreas, neutralize the acidic chyme entering the small intestine from the stomach, creating a more suitable environment for digestive enzymes. Saliva (choice A) helps in the initial breakdown of food in the mouth, not in neutralizing stomach acid. Gastric mucus (choice B) protects the stomach lining from the acidic environment but does not neutralize the acid in the small intestine. Enzymes (choice D) facilitate chemical reactions in digestion but do not neutralize stomach acid.
5. A nurse is caring for a patient who is being treated for leukemia in the hospital. The patient was able to maintain her nutritional status for the first few weeks following her diagnosis but is now exhibiting early signs and symptoms of malnutrition. In collaboration with the dietitian, what intervention should the nurse implement?
- A. Arrange for total parenteral nutrition (TPN).
- B. Facilitate placement of a percutaneous endoscopic gastrostomy (PEG) tube.
- C. Provide the patient with several small, soft-textured meals each day.
- D. Assign responsibility for the patient's nutrition to the patient's friends and family.
Correct answer: C
Rationale: For patients experiencing difficulties with oral intake, the provision of small, easily chewed meals may be beneficial. Option A (TPN) and B (PEG tube placement) are more invasive interventions and should be considered if non-oral routes are necessary. Option D is not appropriate as the primary responsibility for a patient's nutrition should lie with healthcare professionals to ensure proper management and monitoring.
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