ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A nurse is teaching a newly hired group of unlicensed assistive personnel about infection-control measures on the unit. What is the most effective way to prevent the spread of pathogens during client care?
- A. Properly dispose of contaminated equipment
- B. Perform hand hygiene
- C. Discard used syringes into appropriate containers
- D. Change soiled linens
Correct answer: Perform hand hygiene
Rationale:
2. A client requests information on the use of Feverfew. Which of the following responses should the nurse make?
- A. It is used to treat skin infections.
- B. It can decrease the frequency of migraine headaches.
- C. It can lessen nasal congestion in the common cold.
- D. It can relieve nausea of morning sickness during pregnancy.
Correct answer: B
Rationale: The correct response is B: Feverfew is commonly used to decrease the frequency of migraine headaches. However, it is important to note that it has not been proven to relieve an existing migraine headache. Choices A, C, and D are incorrect as Feverfew is not typically used for treating skin infections, lessening nasal congestion in the common cold, or relieving nausea of morning sickness during pregnancy.
3. A client received IV Verapamil to treat supraventricular tachycardia (SVT). The client's pulse rate is now 98/min, and blood pressure is 74/44 mm Hg. The nurse should anticipate a prescription for which of the following IV medications?
- A. Calcium gluconate
- B. Sodium bicarbonate
- C. Potassium chloride
- D. Magnesium sulfate
Correct answer: A
Rationale: In this situation, where the client's blood pressure is significantly lowered due to Verapamil administration, the nurse should anticipate a prescription for Calcium gluconate. Calcium gluconate is used to reverse severe hypotension caused by Verapamil. It should be given slowly intravenously as it counteracts the vasodilation caused by Verapamil, helping to normalize blood pressure levels. Sodium bicarbonate is not indicated for low blood pressure. Potassium chloride and magnesium sulfate are not the appropriate choices to address hypotension caused by Verapamil.
4. A healthcare provider is caring for a client who has a new prescription for Epoetin Alfa. Which of the following laboratory values should the healthcare provider monitor?
- A. WBC count.
- B. Platelet count.
- C. Hemoglobin.
- D. Serum potassium.
Correct answer: C
Rationale: Epoetin alfa is a medication that stimulates red blood cell production, so hemoglobin levels should be monitored to assess the effectiveness of the drug. Monitoring hemoglobin levels helps evaluate the response to Epoetin Alfa treatment and ensures that the client's anemia is being appropriately managed.
5. A client is receiving magnesium sulfate for the management of preeclampsia. Which of the following client assessments should the nurse monitor to prevent complications of therapy?
- A. Bowel sounds
- B. Deep tendon reflexes
- C. Oxygen saturation
- D. Fluid balance
Correct answer: B
Rationale: The correct answer is deep tendon reflexes. Monitoring deep tendon reflexes is crucial to assess for magnesium toxicity during therapy for preeclampsia. Magnesium sulfate can lead to neuromuscular blockade, reflected by decreased or absent deep tendon reflexes. Assessing bowel sounds (choice A) is important for gastrointestinal function but is not directly related to magnesium sulfate therapy. Oxygen saturation (choice C) is vital for respiratory status but is not specifically linked to magnesium sulfate administration. Fluid balance (choice D) is essential but does not directly correlate with monitoring for complications of magnesium sulfate therapy in the context of preeclampsia.
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