ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client arrives speaking only Spanish. What is the priority nursing intervention?
- A. Give the client a tour of the unit
- B. Verify the reason for admission
- C. Request a medical interpreter
- D. Call the chaplain for support
Correct answer: Request a medical interpreter
Rationale:
2. What is an advantage of the ventrogluteal muscle as an injection site in young children?
- A. Easily accessible from many directions
- B. Free of significant nerves and vascular structures
- C. Can be used until the child reaches a weight of 9 kg (20 lb)
- D. Increased subcutaneous fat, which provides sustained drug absorption
Correct answer: B
Rationale: The ventrogluteal site is free of significant nerves and vascular structures, making it a safer choice for intramuscular injections in young children compared to other sites that may be more prone to complications.
3. A nurse is planning care for a client who has dementia and is frequently agitated. Which of the following interventions should the nurse include in the plan of care?
- A. Offer the client several choices when scheduling activities.
- B. Confront the client when inappropriate behavior occurs.
- C. Use a calm, reassuring approach when speaking to the client.
- D. Encourage the client to engage in stimulating activities.
Correct answer: C
Rationale: The correct intervention for a client with dementia who is frequently agitated is to use a calm and reassuring approach when speaking to them. This approach helps reduce agitation and create a more therapeutic environment. Offering several choices may overwhelm the client and increase agitation, making choice A incorrect. Confronting the client can escalate the situation and worsen agitation, making choice B inappropriate. While encouraging stimulating activities is beneficial, it may not be the most effective intervention for immediate agitation management, making choice D less priority compared to using a calm and reassuring approach.
4. A client has an infection and a prescription for gentamicin intermittent IV bolus every 8 hr. A peak and trough is required with the next dose. Which of the following actions should be taken to obtain an accurate gentamicin serum level?
- A. Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose.
- B. Draw a peak level 90 min prior to administering the medication and a trough level 90 min after the dose.
- C. Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose.
- D. Draw a peak level at 0900 and a trough level at 2100.
Correct answer: C
Rationale: To obtain an accurate gentamicin serum level, the trough should be drawn immediately before administering the medication, and the peak level should be drawn 30 minutes after the dose. This timing allows for the assessment of the lowest and highest drug concentrations in the bloodstream, ensuring therapeutic levels are achieved while minimizing the risk of toxicity. Choice A is correct as it follows this timing protocol. Choices B and D have incorrect timing for peak and trough levels, which would not provide an accurate representation of the drug's concentration in the bloodstream.
5. A client with asthma has a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide?
- A. Check the pulse after using the inhaler.
- B. Take the medication with food.
- C. Rinse the mouth after using the inhaler.
- D. Reduce caffeine consumption.
Correct answer: C
Rationale: The correct answer is C: 'Rinse the mouth after using the inhaler.' Rinsing the mouth after using inhaled beclomethasone is crucial to prevent fungal overgrowth in the mouth, a common side effect of corticosteroid inhalers. Checking the pulse after using the inhaler (Choice A) is not directly related to the use of beclomethasone. Taking the medication with food (Choice B) is not a specific instruction for inhaled beclomethasone. While reducing caffeine consumption (Choice D) can be beneficial for some health conditions, it is not a specific instruction related to using inhaled beclomethasone.
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