a nurse is reviewing the prescriptions for a client who has a pneumothorax which of the following actions should the nurse perform first

ATI RN

ATI Fundamentals Proctored Exam Quizlet

1. When reviewing the prescriptions for a client with a pneumothorax, which of the following actions should the nurse perform first?

A. Assess the client's pain.
B. Obtain a large-bore IV needle for decompression.
C. Administer lorazepam.
D. Prepare for chest tube insertion.

Correct answer: B

Rationale: In a client with a pneumothorax, the priority action for the nurse is to obtain a large-bore IV needle for decompression. This intervention helps to relieve the pressure in the pleural space, allowing the lung to re-expand. Prompt decompression is crucial in managing a tension pneumothorax, which can be life-threatening. Assessing pain, administering medication, and preparing for chest tube insertion are important, but they should follow the immediate intervention of decompression in a critical situation like a tension pneumothorax.

2. How many ounces are in 1 cup?

A. 8
B. 80
C. 800
D. 8000

Correct answer: A

Rationale: 1 cup is equivalent to 8 ounces. This conversion is commonly used in cooking and baking recipes, where precise measurements are crucial for the successful outcome of dishes. Knowing this conversion helps ensure that ingredients are accurately measured and the recipe turns out as intended. Choices B, C, and D are incorrect because they do not reflect the correct conversion between cups and ounces. 80, 800, and 8000 ounces are significantly higher quantities than what is found in 1 cup, which is 8 ounces.

3. How many drops are equivalent to 1 tsp?

A. 15
B. 60
C. 10
D. 30

Correct answer: B

Rationale: 1 teaspoon (tsp) is equivalent to approximately 60 drops. Drops and teaspoons vary in volume and size, affecting the conversion ratio. Choice A (15 drops) is incorrect as it's a common misconception. Choice C (10 drops) and Choice D (30 drops) do not align with the standard conversion of 1 tsp to 60 drops.

4. A patient requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?

A. Diabetes mellitus
B. Shoulder presentation
C. Postterm with oligohydramnios
D. Chorioamnionitis

Correct answer: C

Rationale: Postterm pregnancy with oligohydramnios is a contraindication for the use of oxytocin due to the increased risk of uterine hyperstimulation and fetal distress. Oxytocin can further stress the fetus in this scenario, potentially leading to adverse outcomes. Therefore, it is crucial for the nurse to recognize this contraindication to ensure the safety of both the mother and the baby during labor.

5. Which of the following principles of primary nursing has proven most satisfying to the patient and nurse?

A. Continuity of patient care promotes efficient and cost-effective nursing care.
B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

Correct answer: D

Rationale: The holistic approach, encompassing a therapeutic relationship, continuity, and efficient nursing care, is the most satisfying principle of primary nursing. This approach considers the patient as a whole, taking into account physical, emotional, social, and spiritual aspects, which enhances the nurse-patient relationship and promotes comprehensive care. It emphasizes individualized care delivery, continuity of care, and an integrated approach, leading to improved patient satisfaction and nurse fulfillment.