a nurse is assessing the iv infusion site of a client who reports pain at the site the site is red and there is warmth along the course of the vein wh a nurse is assessing the iv infusion site of a client who reports pain at the site the site is red and there is warmth along the course of the vein wh
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. While assessing the IV infusion site of a client experiencing pain, redness, and warmth, what should the nurse do?

Correct answer: B

Rationale: The correct answer is to discontinue the infusion. Pain, redness, and warmth at the IV site are signs of phlebitis, which is inflammation of the vein. Continuing the infusion can further irritate the vein and lead to complications. Increasing the IV flow rate would exacerbate the issue by delivering more irritants to the vein. Elevating the limb and applying a cold compress are not the appropriate interventions for phlebitis, as discontinuing the infusion is crucial to prevent further harm.

2. When teaching parents of a school-age child about transdermal Methylphenidate, which instruction should the nurse include?

Correct answer: B

Rationale: When administering transdermal Methylphenidate, the patch should be left on for 9 hours per day to ensure optimal absorption and effectiveness of the medication. This duration helps maintain a consistent level of the drug in the child's system. Incorrect options: A) Applying one patch once per day is not the correct dosing regimen for transdermal Methylphenidate. C) The patch should not be applied to the child's waistline as it is recommended to apply it to a clean, dry area. D) Using the opened tray within 6 months is not directly related to the administration of transdermal Methylphenidate.

3. What teaching should be provided to a patient after cataract surgery?

Correct answer: A

Rationale: The correct teaching to provide to a patient after cataract surgery is to avoid NSAIDs. NSAIDs should be avoided to reduce the risk of bleeding post-surgery. Choices B, C, and D are not directly related to post-cataract surgery care. Avoiding bright lights and wearing dark glasses while outdoors may be beneficial for eye comfort but are not specific postoperative instructions. Using warm compresses is also not a standard teaching after cataract surgery.

4. What should the nurse do when a patient experiences abdominal cramping during enema administration?

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. Lowering the height helps relieve cramping by slowing down the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is incorrect as it does not directly address the cramping issue. Choice C, continuing the enema at a slower rate, could potentially worsen the cramping by prolonging the discomfort. Choice D, increasing the flow of the enema solution, is also incorrect as it may intensify the cramping and cause more discomfort to the patient.

5. The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?

Correct answer: A

Rationale: Fatigue and weakness are common side effects of radiation therapy, often due to the body’s response to radiation damage and the energy required to repair both cancerous and healthy cells affected by the treatment. Reassuring the patient that these symptoms are expected while also emphasizing ongoing monitoring (through lab and x-ray studies) provides both comfort and a sense of proactive care. It ensures the patient that their symptoms are being addressed in a safe and medically appropriate way.

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