the nurse is preparing to assist in examining a hispanic child who was brought to the clinic by the mother during the assessment of the child the nur
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 4

1. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

Correct answer: C

Rationale: In a multicultural healthcare setting, it's essential for the nurse to build rapport with the child and family. Admiring the child can help establish trust and comfort. Additionally, since the child's mother brought them to the clinic, it's crucial to ensure effective communication. Obtaining an interpreter, if necessary, is vital for clear and accurate information exchange. Taking the child's temperature, while important in a physical assessment, is not specifically highlighted in this scenario. Therefore, choices A and B alone are not sufficient, making the correct answer C, which includes both building rapport by admiring the child and ensuring clear communication by obtaining an interpreter if needed.

2. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?

Correct answer: D

Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering the medication as the blood pressure is within a normal range for a client with essential hypertension. Choice B is not directly related to the administration of a beta blocker. Choice C suggests a potential side effect of an ACE inhibitor, not a beta blocker.

3. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?

Correct answer: B

Rationale: The correct answer is 'Decreased urine output.' Embolization of vegetative lesions from the mitral valve can cause renal infarction, leading to a decrease in urine output. This complication is due to the obstruction of blood flow to the kidneys. Choices A, C, and D are incorrect because embolization from the mitral valve typically does not directly cause pulmonary embolism, hemoptysis, or deep vein thrombosis.

4. What is the mission of the Army Medical Department?

Correct answer: C

Rationale: The correct answer is C: 'Maintain the health of the Army and conserve its fighting strength.' This mission statement reflects the primary goal of the Army Medical Department, which is to ensure the overall health and readiness of military personnel. Choices A, B, and D are incorrect because they do not fully capture the core purpose of the Army Medical Department. While providing physical examinations, healthcare in disaster areas, and education/training are important aspects, the central mission is to uphold the health and combat readiness of the Army.

5. During a synchronized cardioversion on a client in atrial fibrillation, when the machine is activated and there is a pause, what action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when there is a pause after activating the machine for synchronized cardioversion on a client in atrial fibrillation is to shout “all clear” and not touch the bed. This step is crucial to ensure the safety of everyone present by warning them that the machine will discharge, preventing anyone from being inadvertently shocked. Waiting for the machine to discharge (choice A) is not recommended as it can lead to accidental injury. While ensuring the client is all right (choice C) is important, the immediate focus should be on safety during the procedure. Increasing the joules and re-discharging (choice D) without assessing the situation can pose risks to the client and the healthcare team.

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