a nurse is preparing to administer an iv medication to a client who has an allergy to latex which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse is preparing to administer an IV medication to a client who has an allergy to latex. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when preparing to administer IV medication to a client with a latex allergy is to administer the medication through a latex-free IV port. This is crucial as it prevents direct contact of the medication with latex, reducing the risk of an allergic reaction. Choice A is incorrect as using latex gloves can still expose the client to latex. Choice B is not the best option since the administration route is not specified, and using a latex-free syringe alone may not be sufficient to prevent exposure. Choice D is not the most appropriate because the IV tubing and ports should also be latex-free to ensure complete avoidance of latex contact.

2. A client has a new diagnosis of hypertension, and a nurse is teaching about dietary management. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is A: Limit your sodium intake to 2,000 mg per day. Limiting sodium intake helps manage hypertension by reducing fluid retention and lowering blood pressure. Choice B is incorrect because increasing intake of high-fat foods can worsen hypertension by contributing to weight gain and other cardiovascular risks. Choice C is incorrect as green, leafy vegetables are beneficial for hypertension due to their high potassium and other nutrient content. Choice D is incorrect as limiting potassium intake is typically not recommended for hypertension management unless specified by a healthcare provider.

3. A nurse is assessing a school-age child with a urinary tract infection. Which symptom should the nurse expect?

Correct answer: C

Rationale: Enuresis is a common symptom of urinary tract infections in school-age children. It is often a presenting symptom due to irritation of the bladder. Periorbital edema (Choice A) is more indicative of conditions like nephrotic syndrome or renal disorders. Decreased frequency of urination (Choice B) is not typically associated with urinary tract infections. Diarrhea (Choice D) is not a common symptom of urinary tract infections but may occur due to other reasons like gastrointestinal infections.

4. A nurse is providing discharge teaching to a client who had a stroke. What instruction should the nurse provide?

Correct answer: C

Rationale: The correct answer is C: 'Take medications at the same time every day.' Consistency in medication administration is crucial for stroke recovery to maintain therapeutic drug levels in the body. Choice A, 'Avoid lifting more than 5 pounds,' though important to prevent strain, is not directly related to medication adherence. Choice B, 'Perform range-of-motion exercises daily,' is beneficial for overall recovery but is not specific to medication management. Choice D, 'Monitor blood pressure daily,' is important but does not address the key aspect of medication regimen adherence.

5. A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask the client in this situation is whether they have any active lesions due to the history of herpes simplex virus. This is crucial to assess the risk of transmission to the newborn during labor. Option A is not the priority in this case as the focus is on the client's history of herpes simplex virus. Option B is important but does not directly relate to the risk of herpes simplex virus transmission. Option D is unrelated to the client's condition and the current situation.

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