ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. A nurse misreads a glucose reading and administers insulin for a blood glucose of 210 instead of 120. What should the nurse monitor the patient for?
- A. Monitor for hyperglycemia
- B. Monitor for signs of hypoglycemia
- C. Administer glucose IV
- D. Document the incident
Correct answer: B
Rationale: The correct answer is B: Monitor for signs of hypoglycemia. The nurse should monitor the patient for hypoglycemia due to the administration of excess insulin. Administering insulin for a blood glucose level of 210 instead of 120 can lead to a rapid drop in blood sugar levels, causing hypoglycemia. Option A is incorrect as hyperglycemia is high blood sugar, which is unlikely in this scenario. Option C is incorrect as administering glucose IV would worsen the hypoglycemia. Option D is not the immediate priority; patient safety and monitoring for adverse effects take precedence.
2. What are the dietary recommendations for a patient with pre-dialysis end-stage kidney disease?
- A. Reduce phosphorus intake to 700 mg/day
- B. Limit sodium intake to 1,500 mg/day
- C. Restrict protein intake to 0.55-0.60 g/kg/day
- D. Increase protein intake
Correct answer: A
Rationale: The correct recommendation for a patient with pre-dialysis end-stage kidney disease is to reduce phosphorus intake to 700 mg/day. High phosphorus levels can be harmful to individuals with kidney disease as the kidneys may not be able to filter it effectively. While limiting sodium intake to 1,500 mg/day and restricting protein intake to 0.55-0.60 g/kg/day are important in managing kidney disease, the primary concern for this patient population is to control phosphorus levels. Increasing protein intake is not recommended as it can put additional strain on the kidneys. Therefore, option A is the most appropriate recommendation in this scenario.
3. What are the dietary instructions for a patient with pre-dialysis end-stage kidney disease?
- A. Increase protein intake
- B. Reduce sodium intake
- C. Reduce potassium intake
- D. Restrict protein intake to 0.55-0.60 g/kg/day
Correct answer: D
Rationale: The correct answer is to restrict protein intake to 0.55-0.60 g/kg/day for a patient with pre-dialysis end-stage kidney disease. Excessive protein intake can worsen kidney function in such patients. Increasing protein intake, as mentioned in choice A, is not recommended due to the strain it puts on the kidneys. While reducing sodium intake, as in choice B, is relevant for managing blood pressure, it is not specifically related to pre-dialysis end-stage kidney disease. Choice C, reducing potassium intake, is important for patients with kidney disease, but it is not the primary dietary instruction for those with pre-dialysis end-stage kidney disease.
4. What are the signs and symptoms of compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized redness and swelling
- C. Fever and infection
- D. Loss of sensation in the affected area
Correct answer: A
Rationale: The signs and symptoms of compartment syndrome include unrelieved pain, pallor, and pulselessness. Unrelieved pain is a key characteristic, indicating tissue ischemia due to increased pressure within a closed anatomic space. Pallor results from compromised blood flow, and pulselessness indicates severe ischemia requiring immediate intervention. Choices B, C, and D are incorrect because localized redness and swelling, fever and infection, and loss of sensation are not specific signs of compartment syndrome. Therefore, the correct answer is A.
5. What ECG change is associated with hyperkalemia?
- A. Flattened T waves
- B. ST depression
- C. Prominent U waves
- D. Elevated ST segments
Correct answer: B
Rationale: The correct ECG change associated with hyperkalemia is ST depression. Hyperkalemia typically presents with ECG changes such as peaked T waves, prolonged PR interval, widened QRS complex, and finally, ST segment depression. Flattened T waves are more commonly associated with hypokalemia. Prominent U waves are seen in hypokalemia as well. Elevated ST segments are not a typical ECG finding in hyperkalemia.
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