ATI Comprehensive Predictor PN

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How should a healthcare professional assess a patient with hyperkalemia?

  • A. Monitor ECG and administer insulin
  • B. Monitor blood glucose levels and provide fluids
  • C. Monitor for muscle weakness and administer calcium gluconate
  • D. Monitor electrolyte levels and provide potassium supplements
Correct Answer: A

Rationale: Corrected Question: When assessing a patient with hyperkalemia, monitoring the ECG and administering insulin are crucial steps. Hyperkalemia can affect the heart's function, leading to life-threatening arrhythmias. Monitoring the ECG helps in identifying any cardiac abnormalities associated with high potassium levels. Administering insulin, along with glucose, helps shift potassium from the bloodstream into the cells, temporarily lowering the potassium levels.

Choice B is incorrect because monitoring blood glucose levels and providing fluids are not the primary interventions for hyperkalemia.

Choice C is incorrect as monitoring for muscle weakness and administering calcium gluconate are not the first-line treatments for hyperkalemia. Calcium gluconate may be used in specific situations to stabilize cardiac cell membranes in severe cases of hyperkalemia.

Choice D is incorrect because monitoring electrolyte levels and providing potassium supplements would worsen hyperkalemia, as the patient already has elevated potassium levels and does not require additional potassium supplementation.

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A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?

  • A. History of gastrointestinal bleeding
  • B. Prothrombin time of 12 seconds
  • C. Platelet count of 180,000/mm³
  • D. Creatinine level of 1.0 mg/dL
Correct Answer: A

Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.

A healthcare professional is reviewing the medical record of a client who underwent surgery for a hip fracture. Which of the following findings should the healthcare professional report to the provider?

  • A. Clear lung sounds
  • B. Fever
  • C. Pain in the operative leg
  • D. Capillary refill of 2 seconds
Correct Answer: B

Rationale: The correct answer is B: Fever. Fever in a postoperative client can indicate an infection, which is a serious complication and should be reported immediately to the provider for further evaluation and management. Clear lung sounds (Choice A) are a positive finding indicating normal respiratory function. Pain in the operative leg (Choice C) is expected postoperatively and should be managed with appropriate pain relief measures. Capillary refill of 2 seconds (Choice D) is within the normal range (less than 3 seconds) and is not a concerning finding postoperatively.

What is the most important nursing action when administering IV potassium?

  • A. Monitor for decreased urine output
  • B. Administer via IV push
  • C. Administer slowly and dilute in IV fluids
  • D. Ensure the client drinks 500 mL of water before administration
Correct Answer: C

Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

  • A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
  • B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
  • C. A client who has epidural analgesia and weakness in the lower extremities.
  • D. A client who has a hip fracture and a new onset of tachypnea.
Correct Answer: D

Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.

A nurse is teaching a client who is to undergo radiation therapy for breast cancer about potential adverse effects. Which of the following adverse effects should the nurse include in the teaching?

  • A. Fatigue
  • B. Constipation
  • C. Hair loss
  • D. Weight gain
Correct Answer: A

Rationale: The correct adverse effect that the nurse should include in the teaching is fatigue. Fatigue is a common side effect of radiation therapy, particularly with prolonged treatment. Constipation, hair loss, and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices. Fatigue can significantly impact a patient's quality of life during treatment and should be addressed proactively by healthcare providers.

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