ATI RN
Fluid and Electrolytes ATI
1. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:
- A. Choose a proximal site.
- B. Choose a distal site.
- C. Have the patient hold their arm in a dependent position.
- D. Leave the tourniquet on for no longer than 2 minutes.
Correct answer: B
Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Opting for a distal site ensures that upper veins remain available for future cannulations. Instructing the patient to hold their arm in a dependent position can enhance blood flow, aiding in the procedure. It is crucial never to leave a tourniquet on for more than 2 minutes as prolonged restriction can lead to complications. Choice A is incorrect because a proximal site is not preferred for IV insertion. Choice C is incorrect as having the patient hold their arm over their head is not necessary and may impede proper blood flow. Choice D is incorrect as leaving the tourniquet on for at least 5 minutes is excessive and can be harmful.
2. When assessing a client with bipolar disorder who is experiencing a depressive episode, which of the following findings should the nurse not expect?
- A. Low energy
- B. Feelings of hopelessness
- C. Insomnia or hypersomnia
- D. Difficulty concentrating
Correct answer: D
Rationale: In a client experiencing a depressive episode in bipolar disorder, common findings include low energy, feelings of hopelessness, insomnia or hypersomnia, and decreased appetite. Difficulty concentrating is more indicative of attention deficit disorders or cognitive impairment rather than a typical presentation of a depressive episode in bipolar disorder.
3. A client with brain cancer and headaches is prescribed dexamethasone. What is the purpose of this adjuvant medication?
- A. To decrease inflammation and swelling
- B. To improve concentration
- C. To induce sedation
- D. To treat depression
Correct answer: A
Rationale: Dexamethasone, a glucocorticoid, is indicated for clients with brain cancer to decrease inflammation and swelling. It helps reduce cerebral edema and relieve pressure caused by the tumor, ultimately alleviating headaches. The purpose of prescribing dexamethasone in this case is not to improve concentration (choice B), induce sedation (choice C), or treat depression (choice D). Methylphenidate, a stimulant, is used for conditions like ADHD, not for brain cancer. Hydroxyzine, an antihistamine, is primarily used for anxiety and itching, not for brain cancer. Amitriptyline, a tricyclic antidepressant, is used for conditions like depression and neuropathic pain, not specifically for brain cancer-related headaches.
4. Which of the following mediates humoral immunity?
- A. Natural killer cells
- B. T cells
- C. B cells
- D. Neutrophils
Correct answer: C
Rationale: Humoral immunity is mediated by B cells, not natural killer cells, T cells, or neutrophils. B cells are responsible for producing antibodies, which are essential components of humoral immunity.
5. The client is on amiodarone and reports blurred vision. What is the nurse’s best response?
- A. Reassure the client that this is a common side effect.
- B. Instruct the client to report this symptom to the healthcare provider immediately.
- C. Advise the client to stop taking the medication.
- D. Discontinue the amiodarone immediately.
Correct answer: B
Rationale: Blurred vision is a potential side effect of amiodarone. Instructing the client to report this symptom to the healthcare provider immediately is the most appropriate response. Choice A is incorrect because although blurred vision can be a common side effect of amiodarone, it should not be dismissed without further evaluation. Choice C is incorrect as advising the client to stop taking the medication without consulting the healthcare provider can be dangerous and is not the first course of action. Choice D is too drastic as discontinuing the medication should be done under the guidance of a healthcare provider after proper evaluation.
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