ATI Learning System PN Medical Surgical Final Quizlet - Nurselytic

Correct Answer: B

Rationale: The correct answer is B: Nausea and vomiting. This finding requires immediate intervention because digoxin toxicity can present with gastrointestinal symptoms like nausea and vomiting. This can indicate an overdose of digoxin, which can be life-threatening. Prompt action is necessary to prevent further complications.

A: Heart rate of 58 beats per minute is within the therapeutic range for digoxin and does not require immediate intervention.
C: Blood pressure of 130/80 mm Hg is also within normal limits and does not indicate an urgent issue.
D: Shortness of breath can be a symptom of heart failure but is not a direct indication of digoxin toxicity requiring immediate intervention.

Correct Answer: A

Rationale: The correct answer is A: Have the patient void immediately before the procedure. This step is crucial to prevent accidental puncture of the bladder during paracentesis. Voiding helps empty the bladder, reducing the risk of injury and ensuring a safer procedure.

Incorrect choices:
B: Position the patient flat in bed - Incorrect, as the patient should be in a sitting position with legs dangling over the side of the bed during the procedure.
C: Administer a full liquid diet - Incorrect, as a full liquid diet is not necessary for paracentesis preparation.
D: Encourage the patient to ambulate for 30 minutes - Incorrect, as ambulation is not relevant to preparing for paracentesis.

Correct Answer: C

Rationale: The most appropriate tool for the nurse to use during the admission assessment of a 75-year-old patient admitted for pancreatitis is the Screening Test-Geriatric Version (SMAST-G). This tool is specifically designed to assess for alcohol abuse in older adults, which is relevant in this case as alcohol consumption can be a risk factor for pancreatitis. The SMAST-G helps identify potential alcohol-related issues in the elderly population, allowing for appropriate interventions and care planning.


Rationale:
A: The Drug Abuse Screening Test (DAST-10) is not the most appropriate tool in this scenario as it focuses on broader drug abuse rather than specifically alcohol abuse.
B: The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is used to assess for alcohol withdrawal symptoms, not alcohol abuse itself.
D: The Mini-Mental State Examination is used to assess cognitive function, which is not directly relevant to the admission assessment for pancreatitis in this case.

Correct Answer: A

Rationale: The correct answer is A: Hepatic encephalopathy. In liver cirrhosis, the liver's ability to detoxify ammonia is impaired, leading to elevated ammonia levels in the blood. This excess ammonia crosses the blood-brain barrier, causing neurological symptoms like confusion and disorientation. Hypoglycemia (
B), electrolyte imbalance (
C), and dehydration (
D) can also contribute to altered mental status, but in a cirrhotic patient, hepatic encephalopathy is the most likely cause due to impaired ammonia metabolism.

Correct Answer: A

Rationale: The correct answer is A: Administer regular insulin intravenously. In DKA, the priority is to lower blood glucose levels and correct acidosis. Regular insulin intravenously is the fastest way to reduce blood glucose levels. Oral hypoglycemic agents (
B) are not effective in DKA. Sodium bicarbonate (
C) is not routinely recommended in DKA as it may worsen acidosis. Providing a high-calorie diet (
D) is not appropriate as the focus should be on treating the underlying condition first.