a nurse is assessing a client who has increased intracranial pressure icp which of the following findings should the nurse expect
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

1. A nurse is assessing a client who has increased intracranial pressure (ICP). Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Tachycardia. In a client with increased intracranial pressure (ICP), tachycardia is a common finding. This is due to the body's compensatory mechanisms in response to the increased pressure. Bradycardia (choice A) is not typically associated with increased ICP and may indicate a different issue. Increased level of consciousness (choice B) is unlikely with increased ICP, as it often leads to altered mental status. Hyperactive bowel sounds (choice D) are not directly related to increased ICP and are more indicative of gastrointestinal issues.

2. A nurse is teaching a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?

Correct answer: C

Rationale: The correct statement the nurse should include is to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is important to manage angina attacks effectively. Option A is incorrect because nitroglycerin sublingual tablets should not be taken with water. Option B is incorrect as nitroglycerin tablets should be stored in their original container at room temperature. Option D is incorrect because there is no specific instruction to avoid foods high in sodium while taking nitroglycerin sublingual tablets.

3. A nurse is preparing to administer a dose of vancomycin IV to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to check the client's creatinine level before administering vancomycin. Vancomycin is known to be nephrotoxic, so assessing the client's renal function before administering the medication is crucial to prevent further kidney damage. Administering the medication over 15 minutes (Choice A) is not the priority in this scenario as renal function assessment takes precedence. Monitoring urine output (Choice B) is important for assessing renal function but checking creatinine level directly provides more accurate information. Assessing for allergies to antibiotics (Choice D) is also important but not as essential as checking the creatinine level due to the nephrotoxic nature of vancomycin.

4. A nurse is preparing to administer vancomycin IV to a client. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action the nurse should take when administering vancomycin IV is to assess the IV site for infiltration during administration. Vancomycin is known to cause tissue damage if it infiltrates, making close monitoring crucial. Administering the medication over 30 minutes (Choice A) is a common practice but not the priority in preventing infiltration. Monitoring for a decrease in blood pressure (Choice B) is not directly related to vancomycin administration. Premedicating with an antiemetic (Choice D) is not typically required for vancomycin administration.

5. A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action the nurse should take when preparing to administer heparin subcutaneously is to administer the medication within 5 cm (2 in) of the umbilicus. This practice ensures proper subcutaneous delivery of the medication. Choice A is incorrect because a smaller gauge needle, typically 25-26 gauge, is used for subcutaneous injections. Choice B is incorrect as heparin should not be injected into the deltoid muscle but rather into fatty tissue. Choice D is incorrect as massaging the injection site after administration can lead to tissue irritation or bruising.

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