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 grains is acceptable for someone with celiac disease?

Correct answer: A

Rationale: The correct answer is A: Rice. Rice is a gluten-free grain, making it safe for individuals with celiac disease. Choices B, C, and D (Rye, Wheat, and Barley) contain gluten and are not suitable for individuals with celiac disease, as gluten can trigger adverse reactions in their bodies.

3. Before administering an MMR (measles, mumps, and rubella) vaccine to a 15-month-old, which question should the nurse ask the mother of the child?

Correct answer: C

Rationale: The correct question the nurse should ask the mother before administering an MMR vaccine to a 15-month-old is whether the child is allergic to any antibiotics. This is crucial because vaccines like MMR contain components that the child could be allergic to, such as neomycin. Checking for antibiotic allergies is essential to prevent adverse reactions to the vaccine. The other options are less relevant in this context. Asking about sore throats, eating habits, or exposure to infections does not directly impact the administration of the MMR vaccine.

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 'Conduct physical training'?

Correct answer: D

Rationale: The correct answer is D: 'Military appearance/physical condition.' The task 'Conduct physical training' aligns with the category of 'Military appearance/physical condition,' as it involves overseeing physical training activities related to maintaining a certain physical standard. Choices A, B, and C are incorrect because 'Accountability' pertains to being answerable for one's actions, 'Personal/professional development' focuses on individual growth and learning, and 'Individual training' is specific to training on a personal level, none of which directly relate to the task of conducting physical training in the context of military appearance and physical condition.

5. After a pericardiocentesis, what interventions should the nurse implement?

Correct answer: D

Rationale: After a pericardiocentesis, the nurse should implement multiple interventions to monitor the client's condition closely. Monitoring vital signs every 15 minutes for the first hour is crucial to detect any immediate changes that may indicate complications. Evaluating the client's cardiac rhythm is important to identify any arrhythmias that may occur due to the procedure. Recording the amount of fluid removed is essential to calculate fluid balance and ensure accurate monitoring of the client's status. Therefore, all the interventions mentioned are necessary to detect and manage any potential issues post-pericardiocentesis. Choices A, B, and C are all essential components of post-procedural care and should be implemented to ensure the client's safety and well-being.

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