ATI RN
ATI n269 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Administer oral corticosteroids: This is the correct action. Clients with Addison's disease have insufficient cortisol production, especially during times of stress or illness. Oral corticosteroids, such as hydrocortisone, are given to replace the deficient hormones and prevent or manage an Addisonian crisis.
Question 2 of 5
A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?
Correct Answer: B
Rationale: Check your urine for ketones when blood glucose levels are greater than 240 mg/dL.: This is the correct instruction. When blood glucose levels exceed 240 mg/dL, it is important to check for ketones in the urine. The presence of ketones can indicate the development of DKA, and early detection can prevent the condition from worsening.
Question 3 of 5
In reviewing admission orders for a patient admitted with SIADH, the nurse should question which order?
Correct Answer: A
Rationale: In SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion), the body retains excessive water, leading to dilutional hyponatremia (low sodium levels). Administering hypertonic saline (3% NS) can exacerbate the condition by rapidly increasing sodium levels, which may cause demyelination of neurons (a condition called osmotic demyelination syndrome). Hypertonic saline is typically only used in severe hyponatremia with neurologic symptoms and should be carefully monitored.
Question 4 of 5
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?
Correct Answer: D
Rationale: Checking the drainage for glucose is the most appropriate initial action. Clear drainage from the nasal packing could indicate a CSF leak, which is a complication that can occur after transsphenoidal surgery. CSF contains glucose, so testing for glucose in the drainage will help determine if it is CSF.
Question 5 of 5
A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Administer oral corticosteroids: This is the correct action. Clients with Addison's disease have insufficient cortisol production, especially during times of stress or illness. Oral corticosteroids, such as hydrocortisone, are given to replace the deficient hormones and prevent or manage an Addisonian crisis.