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

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?

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 nurse is teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes?

Correct answer: D

Rationale: The correct answer is D. In Type 2 diabetes, the primary issue is insulin resistance, where cells do not respond effectively to insulin. Choice A is incorrect because in Type 1 diabetes, the islet cells in the pancreas stop producing insulin. Choice B is not directly related to the development of Type 2 diabetes but rather to its management. Choice C is incorrect as it refers to a dysfunction in vasopressin production, which is not related to Type 2 diabetes.

3. Which of the following statements does NOT apply to a nursing plan of care?

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate needs. Choice C is also accurate as nursing plans of care need to be continually evaluated and updated to ensure they are effective. Choice D is incorrect as nursing plans of care can contain long-range goals to provide a roadmap for the patient's overall care and recovery.

4. The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?

Correct answer: B

Rationale: The correct answer is B: Splenectomy. Splenectomy is the treatment of choice for hereditary spherocytosis. By removing the spleen, the excessive destruction of red blood cells is reduced, preventing hemolysis and improving anemia. Bone marrow transplant (A) is not a standard treatment for hereditary spherocytosis. Frequent blood transfusions (C) may temporarily address anemia but do not treat the underlying cause. Liver biopsy (D) is not indicated as a primary treatment for hereditary spherocytosis.

5. When does short-bowel syndrome usually occur?

Correct answer: B

Rationale: Short-bowel syndrome typically occurs when more than 50% of the small intestine is surgically removed. This condition leads to malabsorption issues due to the reduced length of the intestine for absorption. Choices A, C, and D are incorrect because short-bowel syndrome specifically relates to the insufficient length of the small intestine, not the contraction of longitudinal muscles, surgical removal of the large intestine, or decreased transit time due to infection or drugs.

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