a nurse is caring for a client who has a new diagnosis of tuberculosis tb which of the following interventions should the nurse include in the plan of
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). Which of the following interventions should the nurse include in the plan of care?

Correct answer: A

Rationale: The correct answer is to place the client in a private room with negative airflow. This is crucial for preventing the spread of tuberculosis (TB) infection. Option B, wearing an N95 respirator when caring for the client, is important for staff protection but does not address the need for isolation precautions. Option C, placing the client in a positive pressure room, is incorrect as TB clients should be in negative pressure rooms to prevent the spread of airborne pathogens. Option D, maintaining the client on droplet precautions, is not sufficient for TB, which requires airborne precautions.

2. A nurse is providing teaching to a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C. Clients taking clopidogrel should take the medication with a full glass of water to prevent gastrointestinal irritation. Choice A is incorrect because there is no specific recommendation to avoid foods high in potassium with clopidogrel. Choice B is unrelated to the medication's administration. Choice D is a duplication of choice C, providing no additional information.

3. A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?

Correct answer: D

Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.

4. What is the best intervention for a patient with dehydration?

Correct answer: A

Rationale: Administering IV fluids is the best intervention for a patient with dehydration because it is the fastest and most effective way to rehydrate the body. IV fluids can quickly restore fluid volume and electrolyte balance in severe cases of dehydration. Providing oral fluids or encouraging fluid intake may not be sufficient for patients with moderate to severe dehydration, as they may have impaired gastrointestinal absorption. While electrolytes are essential for rehydration, administering them alone without fluid replacement may not address the primary issue of fluid loss in dehydration.

5. What is the first intervention for a patient experiencing anaphylactic shock?

Correct answer: A

Rationale: The correct answer is to administer epinephrine as the first intervention for a patient experiencing anaphylactic shock. Epinephrine is crucial in reversing the allergic reaction and restoring cardiovascular stability. Corticosteroids (Choice B) are not the first-line treatment for anaphylactic shock but may be used as an adjunct therapy. Antihistamines (Choice C) can help relieve itching and hives but are not as effective as epinephrine in treating the systemic effects of anaphylaxis. Oxygen (Choice D) may be necessary to support breathing in severe cases of anaphylaxis, but administering epinephrine takes precedence in the management of anaphylactic shock.

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