which intervention is most appropriate for a patient experiencing hypoglycemia which intervention is most appropriate for a patient experiencing hypoglycemia
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. What is the most appropriate intervention for a patient experiencing hypoglycemia?

Correct answer: B

Rationale: Providing oral glucose is the correct intervention for a patient experiencing hypoglycemia. Oral glucose helps quickly raise blood sugar levels, making it the preferred treatment for mild hypoglycemia. Administering glucagon (Choice A) is usually reserved for severe cases when the patient cannot take anything by mouth. Administering IV fluids (Choice C) is not the primary intervention for hypoglycemia unless the patient is severely dehydrated. Monitoring blood sugar levels (Choice D) is important but providing glucose is the immediate priority to treat hypoglycemia.

2. Which fluid is used in the management of gastrointestinal tract (GIT) loss and burns?

Correct answer: Ringer’s lactate

Rationale: Ringer’s lactate is the preferred fluid for managing gastrointestinal tract (GIT) losses and burns due to its balanced electrolyte composition. It helps replace lost fluids and electrolytes, making it an ideal choice for resuscitation in such scenarios. Normal saline is commonly used for volume resuscitation but may not be the best choice for these specific conditions. Dextrose is a source of glucose and is not typically used as the primary fluid for GIT losses and burns. Blood transfusion is indicated for specific situations like severe hemorrhage or anemia but is not the primary fluid for GIT losses and burns.

3. When educating a client with a new prescription for Atorvastatin to treat Hyperlipidemia, which instruction should the nurse include?

Correct answer: B

Rationale: The correct instruction for the nurse to include when educating a client with a new prescription for Atorvastatin to treat Hyperlipidemia is to avoid drinking grapefruit juice. Grapefruit juice can increase the blood levels of atorvastatin, leading to an elevated risk of serious side effects such as liver damage and muscle problems. It is essential for the client to be aware of this potential interaction and to follow the nurse's advice to avoid grapefruit juice while taking Atorvastatin. Choices A, C, and D are incorrect. Taking Atorvastatin in the morning is a common recommendation but not the priority over avoiding grapefruit juice. Increasing intake of green, leafy vegetables is generally a healthy dietary choice but is not specific to the medication. Expecting stools to turn clay-colored is not a common side effect of Atorvastatin.

4. What is the priority nursing diagnosis for a client with immobility?

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

5. When a patient is prescribed an oral anticoagulant, what should the nurse monitor for?

Correct answer: C

Rationale: When a patient is prescribed an oral anticoagulant, the nurse should monitor for signs of bleeding. Oral anticoagulants work by inhibiting the blood's ability to clot, which increases the risk of bleeding. Monitoring for signs of bleeding such as easy bruising, petechiae, hematuria, or bleeding gums is crucial to prevent complications. Elevated blood glucose (Choice A) is not directly related to oral anticoagulant use. Decreased blood pressure (Choice B) is not a common effect of oral anticoagulants. Increased appetite (Choice D) is not a typical side effect of oral anticoagulants and is not a primary concern when monitoring a patient on this medication.

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