a nurse in an emergency department is caring for a client who reports cocaine use 1 hour ago which of the following findings should the nurse expect
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse in an emergency department is caring for a client who reports cocaine use 1 hour ago. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: The correct answer is D: Elevated temperature. Cocaine is a stimulant drug that can lead to increased body temperature. Hypotension (Choice A) is less likely as cocaine tends to elevate blood pressure. Memory loss (Choice B) and slurred speech (Choice C) are more commonly associated with depressant drugs rather than stimulant drugs like cocaine.

2. A nurse is caring for a client who has depression and reports taking St. John's Wort along with citalopram. The nurse should monitor the client for which condition as a result of an interaction between these substances?

Correct answer: B

Rationale: The correct answer is B: Serotonin syndrome. Serotonin syndrome can occur due to the interaction between citalopram, an SSRI, and St. John's Wort, an herbal supplement. Symptoms of serotonin syndrome include confusion, agitation, rapid heart rate, high blood pressure, dilated pupils, loss of muscle coordination, and sweating. Choices A, C, and D are incorrect as they are not typically associated with the interaction between citalopram and St. John's Wort. Tardive dyskinesia is a movement disorder associated with long-term use of certain medications, pseudoparkinsonism is a side effect of certain antipsychotic medications, and acute dystonia is a movement disorder caused by certain medications like antipsychotics.

3. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'Take a tablet every 5 minutes for pain relief, up to three doses.' Nitroglycerin sublingual tablets are used to relieve chest pain or to prevent chest pain before activities known to cause angina. The tablets should be taken every 5 minutes for pain relief, up to three doses, as prescribed. Choice B is incorrect because nitroglycerin sublingual tablets should be placed under the tongue until they dissolve, not taken with water. Choice C is incorrect because nitroglycerin sublingual tablets should not be chewed but placed under the tongue for absorption. Choice D is incorrect because nitroglycerin tablets should be stored in their original container at room temperature away from light and moisture.

4. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?

Correct answer: C

Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.

5. A nurse is teaching a newly licensed nurse about using a portable oxygen system. What instruction should the nurse include?

Correct answer: C

Rationale: The correct answer is to check the oxygen level regularly using a pulse oximeter. This instruction is crucial as it ensures safe and adequate oxygenation for the client. Option A is incorrect as oxygen should not be stored in a storage room but in a well-ventilated area. Option B is not ideal as oxygen should be left on unless otherwise specified by a healthcare provider. Option D is also important but not directly related to the primary instruction of monitoring oxygen levels.

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