what is the priority intervention for a patient with dehydration

ATI RN

ATI Exit Exam RN

1. What is the priority intervention for a patient with dehydration?

A. Administer IV fluids
B. Monitor intake and output
C. Administer oral fluids
D. Provide electrolyte replacement

Correct answer: A

Rationale: The correct answer is to administer IV fluids. This intervention is the priority as it helps rapidly restore hydration in patients with dehydration by delivering fluids directly into the bloodstream. Monitoring intake and output (choice B) is important but comes after providing immediate fluid resuscitation. Administering oral fluids (choice C) may not be sufficient for a patient with dehydration who requires rapid rehydration. Providing electrolyte replacement (choice D) is essential but often follows fluid resuscitation to correct any electrolyte imbalances resulting from dehydration.

2. A client has a new diagnosis of hypertension, and a nurse is teaching about dietary management. Which of the following instructions should the nurse include?

A. Limit your sodium intake to 2,000 mg per day.
B. Increase your intake of high-fat foods.
C. Increase your intake of green, leafy vegetables.
D. Limit your potassium intake to 3,000 mg per day.

Correct answer: A

Rationale: The correct answer is A: Limit your sodium intake to 2,000 mg per day. Limiting sodium intake helps manage hypertension by reducing fluid retention and lowering blood pressure. Choice B is incorrect because increasing intake of high-fat foods can worsen hypertension by contributing to weight gain and other cardiovascular risks. Choice C is incorrect as green, leafy vegetables are beneficial for hypertension due to their high potassium and other nutrient content. Choice D is incorrect as limiting potassium intake is typically not recommended for hypertension management unless specified by a healthcare provider.

3. What is the appropriate diet for a patient with chronic kidney disease?

A. Low protein diet
B. High protein diet
C. Low sodium diet
D. Low potassium diet

Correct answer: A

Rationale: A low protein diet is the appropriate choice for a patient with chronic kidney disease because it helps to reduce the buildup of waste products in the body, which the kidneys may struggle to filter out. High protein diets can put extra strain on the kidneys by increasing the workload to eliminate the byproducts of protein metabolism. While low sodium and low potassium diets can also be important for managing certain aspects of kidney disease, the primary focus should be on controlling protein intake to lessen the burden on the kidneys.

4. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by assessing which of the following?

A. A chest x-ray reveals increased density in all lung fields
B. The client reports feeling less anxious
C. Diminished breath sounds are auscultated unilaterally
D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg

Correct answer: B

Rationale: The correct answer is B. Client-reported improvement in anxiety is an indication of effective treatment for pulmonary embolism. Choice A is incorrect as increased density in all lung fields on a chest x-ray may indicate complications or lack of improvement. Choice C is incorrect as diminished breath sounds auscultated unilaterally may suggest a localized lung issue and not necessarily reflect the effectiveness of treatment for a pulmonary embolism. Choice D is incorrect as the ABG results provided do not specifically indicate the effectiveness of treatment for a pulmonary embolism.

5. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?

A. Insert a lubricated gloved finger and advance along the rectal wall
B. Apply lubricant and stimulate peristalsis
C. Apply pressure to the abdomen to assist with removal
D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma to the client. Choice B is incorrect because stimulating peristalsis is not the appropriate action for digitally evacuating stool. Choice C is incorrect as applying pressure to the abdomen can be uncomfortable and ineffective. Choice D is also incorrect because increasing fluid intake is not directly related to the digital evacuation procedure.