the nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip it is most important for the nurse to include wh

ATI RN

ATI RN Custom Exams Set 3

1. The nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions?

A. Feed the infant with a newborn nipple while holding him in the recumbent position
B. Clean the suture site with a cotton-tipped swab soaked in Betadine
C. Place the infant in the prone position after feeding
D. Feed the infant with a rubber-tipped syringe and burp frequently

Correct answer: D

Rationale: The correct answer is D because feeding the infant with a rubber-tipped syringe reduces the risk of injury to the surgical site and prevents aspiration. Choice A is incorrect because feeding an infant with a cleft lip using a newborn nipple while in the recumbent position can increase the risk of aspiration. Choice B is incorrect as Betadine is not typically used on suture sites due to its cytotoxic effects. Choice C is incorrect because placing the infant in the prone position after feeding can also increase the risk of aspiration.

2. 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.

3. Determining nursing care priorities is a part of which of the following steps in determining and fulfilling the nursing care needs of the patient?

A. Evaluation
B. Planning
C. Implementation
D. Assessment

Correct answer: B

Rationale: Corrected Rationale: Planning in nursing involves setting priorities based on the patient's needs, resources, and desired outcomes. It includes organizing and coordinating care activities to achieve the identified goals. Therefore, determining nursing care priorities is a key aspect of the planning phase.\n Incorrect Rationales:\n- Evaluation (Choice A) comes after implementing the care plan to assess the effectiveness of interventions and make necessary adjustments.\n- Implementation (Choice C) is the phase where the care plan is put into action, involving carrying out the nursing interventions designed during the planning phase.\n- Assessment (Choice D) is the initial step in the nursing process where data about the patient's health status is collected and analyzed to identify needs and formulate a care plan. It precedes planning and determining care priorities.

4. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

A. Secure a clean container
B. Discard the container if the outside becomes dirty
C. Rinse the client's mouth with Listerine before collection
D. Tell the client that 4 tablespoons of sputum are needed

Correct answer: A

Rationale: The correct answer is to secure a clean container before sputum collection. This is essential to prevent contamination of the specimen, ensuring accurate test results and avoiding the introduction of external particles or bacteria. Choice B is incorrect because discarding the container if the outside becomes dirty is not necessary; the cleanliness of the inside is crucial. Choice C is incorrect as rinsing the client's mouth with Listerine before collection may introduce unwanted substances that can affect the test results. Choice D is incorrect as the amount of sputum required can vary depending on the test, and specifying a specific amount without medical guidance is not appropriate.

5. Warfarin (Coumadin) is an anticoagulant and interferes with the action of:

A. Platelets
B. Vitamin K
C. Calcium
D. Vitamin B12

Correct answer: B

Rationale: The correct answer is B: Vitamin K. Warfarin inhibits the action of vitamin K, which is essential for blood clotting. By interfering with the production of certain clotting factors, warfarin helps prevent blood clots. Choices A, C, and D are incorrect because warfarin primarily affects the vitamin K-dependent clotting factors and not platelets, calcium, or vitamin B12.