ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client has an open wound with creamy thick yellow drainage. How would the nurse document this finding?
- A. Purulent
- B. Serosanguinous
- C. Sanguineous
- D. Serous
Correct answer: Purulent
Rationale:
2. A nurse is caring for a client with heart failure receiving digoxin. Which of the following findings should the nurse report to the provider?
- A. Heart rate 60/min.
- B. Blood pressure 110/70 mm Hg.
- C. Serum potassium 4 mEq/L.
- D. Blood pressure 120/80 mm Hg.
Correct answer: B
Rationale: The correct answer is B. A blood pressure of 110/70 mm Hg is a finding that the nurse should report to the provider when caring for a client with heart failure receiving digoxin. Digoxin can cause hypotension, so a low blood pressure reading should be reported promptly to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and would not require immediate reporting. A heart rate of 60/min is considered normal, but any further decrease should be monitored. A serum potassium level of 4 mEq/L is also within the normal range. A blood pressure of 120/80 mm Hg is typically considered normal as well.
3. The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery?
- A. Intestinal obstruction
- B. Fluid and electrolyte imbalance
- C. Malabsorption of fat
- D. Folate deficiency
Correct answer: B
Rationale: Fluid and electrolyte imbalance is a common complication following ileostomy surgery due to the loss of large volumes of fluid and electrolytes through the stoma. Monitoring and replacing fluids and electrolytes is essential.
4. The nurse is administering a beta blocker to a client with a heart rate of 58 bpm. What is the nurse’s priority action?
- A. Administer the beta blocker as ordered.
- B. Hold the beta blocker and notify the healthcare provider.
- C. Increase the dose of the beta blocker.
- D. Monitor the client’s heart rate and reassess in 30 minutes.
Correct answer: B
Rationale: The correct answer is B. A heart rate of 58 bpm is considered low, and beta blockers can further decrease the heart rate. Therefore, the nurse's priority action should be to hold the beta blocker and notify the healthcare provider for further assessment. Choice A is incorrect because administering the beta blocker without considering the low heart rate can worsen the condition. Choice C is incorrect as increasing the dose of the beta blocker can lead to further slowing of the heart rate, which is not safe in this situation. Choice D is not the priority action; holding the medication and seeking guidance from the healthcare provider is more crucial.
5. A client who is postpartum requests information about contraception. Which of the following instructions should the nurse include?
- A. The lactation amenorrhea method is effective for the first year postpartum.
- B. You should not use the diaphragm used before your pregnancy.
- C. Apply the transdermal birth control patch on your upper arm.
- D. Avoid using vaginal spermicides while breastfeeding.
Correct answer: D
Rationale: The correct answer is to advise the client to avoid using vaginal spermicides while breastfeeding. This instruction is important as spermicides can potentially affect the milk supply and cause irritation. Choice A is incorrect because the effectiveness of the lactation amenorrhea method diminishes after the first six months postpartum. Choice B is incorrect as using the diaphragm used before pregnancy may not fit properly due to changes in the body postpartum. Choice C is incorrect as the transdermal birth control patch is typically applied to the abdomen, buttocks, or upper torso, not specifically the upper arm.
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