a nurse is creating a plan of care for a client who is in the late stage of inhalation anthrax which of the following is appropriate to include in the
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Nursing Elites

ATI RN

Adult Medical Surgical ATI

1. A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?

Correct answer: A

Rationale: In the late stage of inhalation anthrax, respiratory support is crucial due to the potential for respiratory failure. Providing oxygen therapy and maintaining airway patency are essential components of care to improve oxygenation and support respiratory function. Placing the client in droplet isolation is not necessary as inhalation anthrax is not transmitted from person to person through respiratory droplets. Administering antihypertensive medications is not indicated in the treatment of inhalation anthrax. Monitoring for ascites is not a priority in the late stage of inhalation anthrax.

2. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?

Correct answer: A

Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.

3. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?

Correct answer: C

Rationale: Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client & partner to be tested for the abnormal gene. The other statements are not true.

4. A client with tuberculosis is starting combination drug therapy. Which of the following medications should the nurse NOT plan to administer?

Correct answer: C

Rationale: Acyclovir is an antiviral medication used to treat herpes virus infections, not tuberculosis. Rifampin, Isoniazid, and Pyrazinamide are all commonly used in the treatment of tuberculosis. Therefore, the nurse should not plan to administer Acyclovir to a client with tuberculosis.

5. A client with asthma has developed viral pharyngitis. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: Viral pharyngitis is typically caused by a virus, not bacteria, so a negative throat culture is an expected finding. The presence of petechiae on the chest and abdomen (Choice A) is not a common manifestation of viral pharyngitis. Elevated WBC count (Choice B) is more indicative of a bacterial infection rather than a viral one. Severe hyperemia of the pharyngeal mucosa (Choice D) is a possible finding in pharyngitis but is not specific to viral pharyngitis.

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