ATI RN
ATI Capstone Medical Surgical Assessment 1 Quizlet
1. The nurse misread a patient's glucose as 210 mg/dL instead of 120 mg/dL and administered the insulin dose for a reading over 200 mg/dL. What is the priority action?
- A. Administer glucose IV
- B. Monitor for hyperglycemia
- C. Monitor for hypoglycemia
- D. Document the incident
Correct answer: C
Rationale: The priority action is to monitor the patient for signs of hypoglycemia as the nurse administered excess insulin due to misreading the glucose level. Administering glucose IV (Choice A) is not the immediate priority when dealing with hypoglycemia. Monitoring for hyperglycemia (Choice B) is not the correct action as the insulin was administered for a higher glucose reading. Documenting the incident (Choice D) is important but not the priority when the patient's safety is at risk due to possible hypoglycemia.
2. A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching?
- A. This medication can cause your urine to turn a dark color.
- B. Expect immediate relief after taking this medication.
- C. Take the medication with a high protein food.
- D. Skip a dose of the medication if you experience dizziness.
Correct answer: A
Rationale: The correct instruction to include in the teaching is that carbidopa/levodopa can cause the client's urine to turn a dark color, which is a harmless effect. It is crucial for the nurse to educate the client about this common side effect. Choice B is incorrect because immediate relief is not expected; therapeutic effects may take weeks to months. Choice C is incorrect as carbidopa/levodopa should be taken on an empty stomach to enhance absorption. Choice D is incorrect as the client should not skip doses without consulting their healthcare provider, even if they experience dizziness.
3. What should be monitored in a patient receiving insulin who is at risk for hypoglycemia?
- A. Monitor blood glucose levels
- B. Monitor for respiratory distress
- C. Monitor for hypertension
- D. Monitor for hyperkalemia
Correct answer: A
Rationale: Corrected Question: In a patient receiving insulin who is at risk for hypoglycemia, monitoring blood glucose levels is crucial. This helps in preventing and identifying hypoglycemia promptly. Choice B, monitoring for respiratory distress, is not directly related to hypoglycemia caused by insulin. Choice C, monitoring for hypertension, is not typically associated with hypoglycemia. Choice D, monitoring for hyperkalemia, is not a common concern in patients receiving insulin who are at risk for hypoglycemia.
4. What is the priority action when the nurse administers insulin for a misread blood glucose reading?
- A. Monitor for signs of hypoglycemia
- B. Monitor for hyperglycemia
- C. Administer glucose IV
- D. Document the incident
Correct answer: A
Rationale: The priority action when the nurse administers insulin for a misread blood glucose reading is to monitor for signs of hypoglycemia. Insulin administration based on a misread blood glucose could lead to hypoglycemia due to an unnecessary dose. Monitoring for signs of hypoglycemia is crucial for prompt intervention if blood glucose levels drop dangerously low. Option B, monitoring for hyperglycemia, is incorrect in this situation as the concern is over-treatment with insulin causing hypoglycemia. Option C, administering glucose IV, is only necessary if hypoglycemia occurs. Option D, documenting the incident, is important for reporting and learning purposes but is not the immediate priority when the focus is on patient safety and preventing complications.
5. What dietary recommendations are given to a patient with pre-dialysis end-stage kidney disease?
- A. Reduce phosphorus intake to 700 mg/day
- B. Increase sodium intake
- 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. Excessive phosphorus intake can be harmful to individuals with kidney disease as their kidneys may not be able to excrete it efficiently. Choice B is incorrect because increasing sodium intake is generally not recommended for patients with kidney disease, as it can contribute to fluid retention and high blood pressure. Choice C is incorrect as protein restriction is commonly advised for individuals with advanced kidney disease to reduce the workload on the kidneys. Choice D is also incorrect as increasing protein intake can further burden the kidneys.
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