ATI-AMS ATI Adult medical surgical Exam - Set 4 - Part 3

Correct Answer: Weight gain from fluid retention

Weight gain from fluid retention is the priority because the excess cortisol promotes sodium and water retention that can lead to pulmonary edema and heart failure. The nurse addresses this circulatory threat ahead of the other findings. Option a is incorrect because thin fragile skin raises a safety concern for injury but does not threaten life the way fluid overload does. It calls for protective measures over time, so it ranks below the weight gain that signals possible cardiac strain. Option b is incorrect because joint pain is uncomfortable but poses no immediate danger to the client's circulation. Because it lacks the urgency of fluid retention that can overload the heart, it is not the priority finding to address first. Option c is incorrect because increased facial hair is a distressing cosmetic effect of excess cortisol and androgens, yet it carries no physiologic emergency. The fluid retention with its risk of heart failure clearly outweighs this finding in priority.

Correct Answer: Avoid brushing your teeth for two weeks

After a transsphenoidal hypophysectomy the client avoids brushing teeth for about two weeks to protect the surgical site. This precaution, along with bending at the knees and limiting coughing, prevents pressure on the healing area and a cerebrospinal fluid leak. Option a is incorrect because nose-blowing raises intracranial pressure and threatens the surgical site, so it is avoided rather than encouraged. Telling the client to blow the nose contradicts the precautions that protect the incision after this procedure. Option c is incorrect because bending at the waist increases pressure at the operative site and risks a cerebrospinal fluid leak. The client is taught to bend at the knees instead, so this instruction works against safe recovery after the surgery. Option d is incorrect because frequent coughing increases intracranial pressure and can disrupt the healing nasal site. The client is instructed to limit coughing, so encouraging it would endanger the surgical area rather than sup

Correct Answer: 'I will increase my dose with stress'

During physical or emotional stress the body needs more cortisol, so the client increases the hydrocortisone dose. Recognizing this need, and keeping an emergency kit, shows the client understood how to prevent an adrenal crisis. Option a is incorrect because stopping a glucocorticoid abruptly can precipitate a life-threatening adrenal crisis. The drug must be tapered rather than discontinued suddenly, so this statement reflects a dangerous misunderstanding of the medication's use. Option b is incorrect because hydrocortisone is taken with food to reduce gastric irritation, not on an empty stomach. Taking it without food increases the risk of stomach upset, so this statement shows the teaching was not understood. Option c is incorrect because clients with Addison's should not restrict sodium and may need extra during vomiting or sweating because aldosterone is deficient. Limiting sodium worsens the salt loss, so this statement reflects a misunderstanding of the dietary needs.

Correct Answer: Draw up the regular insulin first

When mixing insulins the nurse draws up the shorter-acting clear regular insulin before the cloudy NPH. Drawing clear before cloudy prevents contaminating the regular vial with the longer-acting suspension and keeps the rapid dose accurate. Option b is incorrect because drawing up the cloudy NPH first risks introducing it into the regular vial, altering the clear insulin's action. The correct sequence is clear before cloudy, so taking the NPH first reverses the proper mixing order. Option c is incorrect because intermediate insulins such as NPH are given subcutaneously and never intravenously. Injecting NPH into a vein would be unsafe, so this action contradicts the route required for this insulin type. Option d is incorrect because insulin vials are gently rolled, not shaken vigorously, because shaking creates bubbles that affect dosing. Vigorous agitation is improper technique, so it does not belong in the preparation of the insulin doses.

Correct Answer: Give a rapid-acting carbohydrate

For a conscious client with hypoglycemia, the nurse first gives a small amount of rapid-acting carbohydrate by mouth and rechecks the glucose a short time later. Treating the low glucose promptly prevents the serious harm hypoglycemia can cause. Option a is incorrect because giving insulin would lower the blood glucose further and deepen the hypoglycemia. The client needs sugar, not insulin, so administering the next dose is the opposite of the corrective action required here. Option c is incorrect because glucagon is reserved for an unconscious client who cannot safely swallow. Since this client is alert and able to take carbohydrate by mouth, preparing an injection is unnecessary and not the first step. Option d is incorrect because resting quietly does nothing to raise the blood glucose that is causing the symptoms. The client needs fast-acting carbohydrate, so encouraging rest delays the treatment that actually resolves the hypoglycemia.

Correct Answer: Give it when the tray arrives

Insulin aspart is rapid-acting, so it is given just before eating, when the meal tray arrives. Timing the dose with food matches the quick onset and prevents hypoglycemia from acting before the client has eaten. Option a is incorrect because giving rapid-acting insulin a full hour before the meal risks hypoglycemia before food is available. The quick onset means it should be timed with the meal, so dosing this early misjudges the drug's action. Option b is incorrect because bedtime dosing with a snack fits a longer-acting insulin, not a rapid-acting one tied to meals. Administering aspart at night ignores its mealtime purpose, so this timing is incorrect for the medication. Option d is incorrect because rapid-acting insulin is given just before eating rather than after the meal is done. Waiting until afterward leaves the glucose rise uncovered at its peak, so this delayed timing does not match how aspart works.

Correct Answer: Kussmaul respirations and fruity breath

Diabetic ketoacidosis produces deep rapid Kussmaul respirations and fruity acetone breath as the body tries to blow off acid and burns fat. These findings reflect the metabolic acidosis and ketosis the nurse expects to assess. Option b is incorrect because bradycardia with cold clammy skin suggests hypoglycemia or shock rather than the acidotic state of ketoacidosis. This client shows hyperglycemia with warm dry skin, so these findings do not match the condition described. Option c is incorrect because slow shallow breathing is the opposite of the deep rapid Kussmaul pattern seen in ketoacidosis. The body compensates for acid by breathing faster and deeper, so shallow respirations contradict the expected finding. Option d is incorrect because ketones are present in both blood and urine during ketoacidosis, marking the breakdown of fat for fuel. Their absence would argue against the diagnosis, so this finding does not fit a client with this complication.

Correct Answer: Rapid infusion of isotonic sodium chloride

Treatment of diabetic ketoacidosis begins with rapid isotonic sodium chloride to restore the large fluid deficit from osmotic diuresis. Aggressive fluid replacement is the priority before and alongside insulin to correct the dehydration. Option a is incorrect because regular insulin in ketoacidosis is given by continuous IV infusion, not as a subcutaneous bolus, for immediate predictable effect. The subcutaneous route is too slow for this emergency, so this prescription does not fit the situation. Option b is incorrect because dextrose is added once the glucose falls to a moderate level, not after it fully normalizes, to prevent cerebral edema and hypoglycemia. Waiting for a normal value misses the point at which dextrose protects the client during continued insulin. Option d is incorrect because withholding fluids would worsen the profound dehydration that defines ketoacidosis. The client needs rapid volume replacement, so restricting fluids is the opposite of the priority interventio

Correct Answer: Hypokalemia

As insulin drives potassium back into cells, the serum level can fall, so the nurse monitors for hypokalemia. Although potassium starts high in ketoacidosis, the shift during treatment makes a dropping level the key concern. Option b is incorrect because potassium is initially elevated in ketoacidosis, but insulin therapy moves it into cells and lowers the serum level. Continuing to expect a high potassium overlooks this shift, so it is not the imbalance to watch for during treatment. Option c is incorrect because the priority electrolyte concern as insulin works is falling potassium, not rising sodium. While sodium is monitored, a high sodium is not the predictable shift insulin produces, so it does not capture the key risk in this scenario. Option d is incorrect because calcium is not the electrolyte that shifts in response to insulin in ketoacidosis. The insulin-driven movement involves potassium, so focusing on a high calcium level misses the imbalance the nurse should actually ant

Correct Answer: An absence of ketosis and acidosis

Hyperglycemic hyperosmolar state features profound hyperglycemia and dehydration but, unlike ketoacidosis, lacks significant ketosis and acidosis. This absence of ketones and a normal pH is the key feature that distinguishes it from diabetic ketoacidosis. Option a is incorrect because Kussmaul respirations result from the metabolic acidosis of ketoacidosis, which is absent in hyperosmolar state. Because this client is not acidotic, deep rapid breathing does not occur, so it is not what sets the condition apart. Option b is incorrect because a fruity breath odor comes from the ketones of ketoacidosis, which the hyperosmolar state does not produce. Since ketosis is lacking here, this odor would not be present, so it does not distinguish the two conditions. Option d is incorrect because hyperglycemic hyperosmolar state involves extremely high glucose, not a low level. A blood glucose below normal would describe hypoglycemia, the opposite of this disorder, so it does not characterize the c