the nurse is caring for a client who goes into ventricular tachycardia which interventions should the nurse implement first

ATI RN

ATI RN Custom Exams Set 4

1. The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?

A. Call a code immediately
B. Assess the client for a pulse
C. Begin chest compressions
D. Continue to monitor the client

Correct answer: B

Rationale: The correct answer is to assess the client for a pulse. In ventricular tachycardia, the priority is to determine if the client has a pulse. If there is no pulse, immediate initiation of CPR with chest compressions is required. Calling a code or continuing to monitor the client can delay life-saving interventions. Therefore, assessing for a pulse is the most crucial step in managing ventricular tachycardia.

2. The system used at the division level and forward comprises six basic modules. Which module is composed of practical nurses, medical specialists, and equipment to provide medical support for minimal care patients?

A. Treatment squad
B. Patient holding squad
C. Area support squad
D. Surgical squad

Correct answer: B

Rationale: The Patient Holding Squad is the module composed of practical nurses, medical specialists, and equipment to provide medical support for minimal care patients. The other choices are incorrect because a 'Treatment squad' would typically involve a broader range of medical care, an 'Area support squad' is more general and focuses on providing overall support in a specific area, and a 'Surgical squad' would be specifically focused on surgical procedures rather than general medical care for minimal care patients.

3. What intervention would be most important for the nurse to implement for the client with a left nephrectomy?

A. Assess the intravenous fluids for rate and volume
B. Change the surgical dressing daily at the same time
C. Monitor the client’s medication levels daily
D. Monitor the percentage of each meal eaten

Correct answer: A

Rationale: The correct answer is A: Assess the intravenous fluids for rate and volume. After a nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Choice B is incorrect because changing the surgical dressing daily is important but not the most critical intervention. Choice C is incorrect as monitoring medication levels daily may be necessary but is not the priority after a nephrectomy. Choice D is irrelevant to the immediate postoperative care needed after a nephrectomy.

4. Neomycin may decrease absorption of which nutrient?

A. Iron, copper, and zinc
B. Protein and amino acids
C. Fat-soluble vitamins
D. Water-soluble vitamins

Correct answer: C

Rationale: The correct answer is C: Fat-soluble vitamins. Neomycin is known to interfere with the absorption of fat-soluble vitamins. This is because neomycin can disrupt the normal gut flora responsible for the absorption of these vitamins. Choices A, B, and D are incorrect because neomycin primarily affects the absorption of fat-soluble vitamins, not minerals, proteins, amino acids, or water-soluble vitamins.

5. For a patient on lithium therapy, which dietary recommendation is essential?

A. Increase caffeine intake
B. Increase sodium intake
C. Increase protein intake
D. Increase fiber intake

Correct answer: B

Rationale: The correct answer is to increase sodium intake. Maintaining consistent sodium levels is crucial for patients on lithium therapy to prevent fluctuations in drug levels. Increasing caffeine intake (Choice A) is not recommended as it can interfere with lithium levels. While protein intake (Choice C) is important, it is not the essential dietary recommendation for patients on lithium therapy. Similarly, increasing fiber intake (Choice D) is not a key recommendation for these patients.