the client diagnosed with acute vein thrombosis is receiving a continuous heparin drip an intravenous anticoagulant the health care provider orders w
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 2

1. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

Correct answer: D

Rationale: The correct answer is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip before initiating Coumadin can increase the risk of clot formation. Checking the client's INR before starting Coumadin is important but not the immediate action required. Clarifying the order with the healthcare provider is not necessary as both medications are commonly used together.

2. Which of the following describes the four-step method of assessment, planning, implementation, and evaluation?

Correct answer: C

Rationale: The correct answer is C: 'It is a circular process of continued nursing care.' The four-step method of assessment, planning, implementation, and evaluation in nursing is a continuous and cyclical process. Choice A is incorrect because the method is not solely problem-focused; it involves a comprehensive approach. Choice B is incorrect as it does not capture the cyclical nature of the process. Choice D is incorrect as the method is systematic and not based on trial-and-error but rather evidence-based practice.

3. The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?

Correct answer: C

Rationale: Choice C indicates the need for further teaching because regular use of laxatives can lead to dependence and is not recommended for hemorrhoids. Increased fiber intake and fluid consumption (Choice A) help prevent constipation, warm compresses and sitz baths (Choice B) provide relief, and using analgesic ointments or suppositories (Choice D) can help manage pain associated with hemorrhoids.

4. Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task of 'listening and responding to soldiers' suggestions and complaints'?

Correct answer: A

Rationale: The correct answer is A. Accountability in personnel management involves being answerable for one's actions and decisions, which includes listening to and addressing the suggestions and complaints of soldiers. This category focuses on the responsibility and answerability aspect of the nurse manager's role. Choices B, C, and D are incorrect because personal/professional development is about growth and improvement, individual training pertains to specific skill development, and military appearance/physical condition relates to the physical presentation and fitness levels, none of which directly address the task of listening and responding to soldiers' suggestions and complaints.

5. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

Correct answer: A

Rationale: Corrected Rationale: When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Assessing arterial blood gases, skin turgor, or capillary refill time is not directly related to the administration of magnesium sulfate in this scenario.

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