what is the most appropriate action when a patient is experiencing severe dehydration
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ATI RN Exit Exam Test Bank

1. What is the most appropriate action when a patient is experiencing severe dehydration?

Correct answer: A

Rationale: The most appropriate action when a patient is experiencing severe dehydration is to administer IV fluids. This intervention is crucial in rapidly correcting dehydration and restoring fluid balance. Encouraging oral fluids may not be sufficient in cases of severe dehydration where intravenous rehydration is needed. Monitoring electrolytes is important but administering fluids takes precedence in severe dehydration. Performing a neurological exam is not the primary intervention for severe dehydration.

2. What is the best dietary recommendation for a patient with chronic kidney disease?

Correct answer: C

Rationale: The correct answer is a low-sodium diet. Patients with chronic kidney disease are often advised to follow a low-sodium diet to help manage fluid retention. Excessive sodium intake can lead to fluid buildup in the body, causing complications for individuals with kidney issues. Choices A and B are incorrect because while protein intake may need to be monitored in kidney disease, the primary focus is typically on sodium restriction. Choice D is incorrect as a high-sodium diet would exacerbate fluid retention in patients with chronic kidney disease.

3. A nurse is caring for a client who has chronic kidney disease and reports nausea. The nurse should identify that this client is at risk for which of the following imbalances?

Correct answer: B

Rationale: The correct answer is B: Metabolic acidosis. Clients with chronic kidney disease are at risk for metabolic acidosis because the kidneys are unable to effectively excrete acids, leading to an accumulation of acid in the body. This metabolic imbalance can result in symptoms like nausea. Choices A, C, and D are incorrect. Metabolic alkalosis is not typically associated with chronic kidney disease. Respiratory alkalosis is more commonly seen in conditions such as hyperventilation. Respiratory acidosis, on the other hand, is often linked to conditions affecting the lungs or respiratory system, not primarily kidney disease.

4. A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory values should the nurse monitor?

Correct answer: D

Rationale: The correct answer is D, INR. The International Normalized Ratio (INR) is used to monitor the therapeutic effect of warfarin and to adjust the dose as needed. While Prothrombin time (PT) and activated Partial Thromboplastin Time (aPTT) are also related to coagulation studies, monitoring INR specifically helps in managing warfarin therapy. Hemoglobin, on the other hand, is not typically monitored in relation to warfarin therapy.

5. A nurse is teaching a client who has a new prescription for alendronate. Which of the following client statements indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Alendronate should be taken with a full glass of water before breakfast to prevent esophageal irritation and improve absorption. Choice A is incorrect as alendronate is not associated with causing drowsiness. Choice C is incorrect because alendronate can be taken with or without food, so avoiding dairy products is not necessary. Choice D is incorrect as the recommended time to remain upright after taking alendronate is 30 minutes to 1 hour, not just 30 minutes.

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