a nurse is caring for a client who has severe hypertension and is receiving nitroprusside what action should the nurse take a nurse is caring for a client who has severe hypertension and is receiving nitroprusside what action should the nurse take
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A nurse is caring for a client who has severe hypertension and is receiving nitroprusside. What action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client receiving nitroprusside for severe hypertension is to limit light exposure to the IV infusion. Nitroprusside is light-sensitive, and exposure to light can lead to degradation of the medication, reducing its effectiveness. Administering oxygen (Choice A) may be necessary for some clients but is not directly related to the administration of nitroprusside. Monitoring blood pressure every 2 hours (Choice B) is a general nursing intervention for clients with hypertension but does not specifically address the administration of nitroprusside. Attaching an inline filter to the IV tubing (Choice D) is not necessary to address the specific concern of light exposure related to nitroprusside administration.

2. Which statement is true concerning early intervention services for children 0-2 years?

Correct answer: D

Rationale: Early intervention services aim to support a diverse group of children and families without the need for a specific diagnosis. These services are inclusive and provided to all eligible children and families, regardless of their background or particular condition.

3. What is the therapeutic classification of Furosemide?

Correct answer: B

Rationale: Furosemide is classified therapeutically as a diuretic. Diuretics are medications used to promote diuresis, which helps the body get rid of excess salt and water. Furosemide is commonly prescribed to treat conditions such as fluid retention and swelling (edema) associated with congestive heart failure, liver disease, or kidney disorders. Choice A, Antidiuretics, is incorrect as Furosemide acts as a diuretic, promoting the production of urine. Choice C, Anticonvulsants, is also incorrect as Furosemide is not used to treat seizures. Choice D, Antidotes, is incorrect as Furosemide is not an antidote but rather a medication used to treat conditions related to fluid retention.

4. Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?

Correct answer: D: Risk for infection

Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.

5. A patient who reports stomach ulcers should avoid all the following foods, except one. Which is the exception?

Correct answer: D

Rationale: Patients with stomach ulcers are advised to avoid foods that can increase stomach acid levels, such as caffeine, proteins, and calcium. Wheat, on the other hand, is generally well-tolerated by individuals with ulcers as it does not stimulate gastric secretions. Therefore, the correct answer is D. Choice A (Proteins), B (Caffeine), and C (Calcium) are not recommended for patients with stomach ulcers due to their potential to exacerbate symptoms.

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