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

ATI RN

ATI Comprehensive Exit Exam

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

Correct answer: D

Rationale: The correct action the nurse should take when preparing to administer an IV medication to a client with a latex allergy is to administer the medication through a latex-free IV port. This measure helps prevent allergic reactions in clients with a known latex allergy. Placing the client in a supine position (Choice A) is not directly related to preventing a latex allergy reaction. Using non-latex gloves (Choice B) is important for protecting the nurse or caregiver from latex exposure but does not prevent the client's allergic reaction. While using latex-free syringes (Choice C) is a good practice, ensuring the IV port is latex-free is more crucial in preventing an allergic response in the client.

2. A client with a new diagnosis of hypertension is being taught about lifestyle changes by a nurse. Which of the following recommendations should the nurse include?

Correct answer: A

Rationale: The correct recommendation for a client with hypertension is to limit sodium intake to no more than 1,500 mg per day. This helps manage hypertension by reducing fluid retention and lowering blood pressure. Choice B is a good recommendation as well, but the primary focus for hypertension management in this scenario is limiting sodium. Choices C and D are incorrect as dairy products and carbohydrates are not directly linked to hypertension.

3. A nurse is caring for a client who has deep-vein thrombosis (DVT) and is receiving heparin therapy. Which of the following laboratory values indicates that the client's heparin therapy is effective?

Correct answer: A

Rationale: An aPTT of 75 seconds indicates that heparin therapy is within the therapeutic range for a client with DVT. The activated partial thromboplastin time (aPTT) is used to monitor heparin therapy's effectiveness. Choice B, INR 1.2, is not the correct answer because INR is used to monitor the effectiveness of warfarin, a different anticoagulant, not heparin. Choice C, Hemoglobin 10 g/dL, is not a measure of heparin therapy effectiveness. Choice D, Fibrinogen level 350 mg/dL, is not a specific indicator of heparin therapy effectiveness for DVT.

4. How should a healthcare provider care for a patient who is refusing medication?

Correct answer: A

Rationale: When a patient refuses medication, it is essential for the healthcare provider to assess the reasons for refusal. This allows the provider to understand the patient's concerns, provide education or clarification if needed, and work collaboratively with the patient to find a solution. Exploring alternative treatment options may be necessary after understanding the reasons behind the refusal. Documenting the refusal is important for legal and continuity of care purposes, but it is not the initial action to take. Discontinuing the medication without understanding the patient's reasons for refusal can lead to potential harm and is not a recommended approach.

5. A nurse is providing teaching to a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is to instruct the client to rotate the patch site each time they apply it. This practice helps prevent skin irritation and ensures the effectiveness of nitroglycerin transdermal patches. Applying the patch to the same site each time can lead to skin irritation and decreased patch efficacy. Choices A, B, and D are incorrect because applying the patch to the upper arm, removing it before showering, and placing it on the lower abdomen do not promote proper rotation of patch sites, which is essential for optimal outcomes.

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