a nurse is caring for a newborn who is 1 day old and receiving phototherapy for jaundice which of the following actions should the nurse take
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ATI Exit Exam 180 Questions Quizlet

1. A nurse is caring for a newborn who is 1-day-old and receiving phototherapy for jaundice. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent skin irritation during phototherapy. Choice A is incorrect as newborns should be breastfed or formula-fed, not given glucose water. Choice B is unnecessary and may interfere with the effectiveness of phototherapy. Choice D is inappropriate as lotions can interfere with the phototherapy and increase the risk of skin damage.

2. A nurse is preparing to administer potassium chloride IV to a client who has hypokalemia. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action the nurse should take when administering potassium chloride IV to a client with hypokalemia is to infuse the medication at a rate of 10 mEq/hr. This slow infusion rate is crucial to prevent the development of hyperkalemia, a potentially dangerous condition. Option A is incorrect because giving the medication as a bolus over 10 minutes can lead to adverse effects. Option B is incorrect as potassium chloride does not necessarily need to be diluted before administration in this scenario. Option D is incorrect as administering the medication undiluted can also increase the risk of hyperkalemia.

3. A nurse is caring for a client who is 3 days postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: A temperature of 37.8°C (100°F) should be reported to the provider as it can indicate infection, a common postoperative complication. A normal heart rate of 80/min (Choice A), white blood cell count of 9,000/mm3 (Choice B), and blood pressure of 118/78 mm Hg (Choice D) are within normal ranges and do not necessarily indicate a complication postoperatively.

4. A client with heart failure is being educated by a nurse about fluid restrictions. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C: "Avoid drinking more than 1 liter of fluid per day." Clients with heart failure are typically advised to limit their fluid intake to around 1 liter per day to prevent fluid overload, which can worsen their condition. Choices A, B, and D are incorrect because they suggest fluid intakes that are higher than the recommended limit, which could lead to fluid retention and exacerbate heart failure symptoms.

5. What is the best way to monitor for infection in a patient with a central line?

Correct answer: A

Rationale: The correct answer is A: Check the central line site daily. Monitoring the central line site daily is crucial in detecting early signs of infection, such as redness, swelling, tenderness, or drainage. By checking the site regularly, healthcare providers can take prompt action to prevent complications. Choice B, monitoring the patient's vital signs, while important in assessing overall health, may not specifically indicate an infection related to the central line. Choice C, checking the central line dressing every other day, may not be frequent enough to catch early signs of infection. Choice D, checking for signs of sepsis, is important but represents a more severe stage of infection and may occur after local signs at the central line site have already manifested.

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