ATI RN
ATI n269 Med Surg Exam Questions
Extract:
Question 1 of 5
A patient's status post hypophysectomy had drainage on the mustache dressing. Which complication is this patient at risk for if the glucose level of the drainage is 50 mg/dL?
Correct Answer: C
Rationale: The presence of glucose in the drainage indicates a possible cerebrospinal fluid (CSF) leak, as CSF contains glucose. A CSF leak increases the risk of meningitis due to the direct connection to the central nervous system.
Question 2 of 5
A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following?
Correct Answer: B
Rationale: 4 oz skim milk: This is the correct choice. Skim milk contains both lactose (a sugar) and protein, which can help raise the blood glucose and stabilize it over a longer period. This is a suitable option for treating mild hypoglycemia.
Question 3 of 5
Which response is best when a patient refuses a stool softener after pituitary surgery?
Correct Answer: C
Rationale: It is important you do not strain during bowel movements because this could result in increased pressure on your surgical site.: This is the correct response. Straining during bowel movements can increase ICP, which could potentially compromise healing or lead to complications after pituitary surgery.
Question 4 of 5
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)
Correct Answer: B,C,E
Rationale: Tachycardia, blurred vision, and moist, clammy skin are all manifestations of hypoglycemia. Polyuria and polydipsia are symptoms of hyperglycemia, not hypoglycemia.
Question 5 of 5
After giving 6 oz of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dl. Which nursing intervention would be the most appropriate in this situation?
Correct Answer: A
Rationale: After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.