a nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic which of the following should be the a nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic which of the following should be the
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Nursing Elites

ATI RN

ATI RN Adult Medical Surgical Online Practice 2023 A

1. A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?

Correct answer: Count the respiratory rate

Rationale: When suspecting anaphylaxis, the priority intervention is to assess the client's respiratory status by counting the respiratory rate. Respiratory distress is a hallmark sign of anaphylaxis, and prompt recognition and management are crucial. Administering oxygen may be necessary, but assessing the respiratory rate takes precedence to determine the severity of the reaction and the need for immediate intervention. Inserting an IV line and preparing for intubation are important interventions in managing anaphylaxis but are secondary to ensuring adequate ventilation.

2. A nurse is providing teaching to a group of older adults about sources of complete and incomplete protein. Which of the following foods should the nurse include as a complete protein?

Correct answer: A: Yogurt

Rationale: Yogurt is the correct answer as it is a complete protein source, containing all nine essential amino acids. Fresh vegetables, nuts, and dried beans are incomplete protein sources as they lack one or more essential amino acids required by the body.

3. Research conducted by Miller and Rahe in 1997 demonstrated a correlation between the effects of life changes and illness, leading to the development of the Recent Life Changes Questionnaire (RLCQ). Which principle most limits the effectiveness of this tool?

Correct answer: D

Rationale: The main limitation of the Recent Life Changes Questionnaire (RLCQ) is that it does not consider an individual's personal perception of a life event. As people may interpret events differently, their subjective perspective plays a crucial role in how they experience stress and its potential impact on their health. Ignoring personal perception limits the effectiveness of the tool as it fails to capture the variations in how people respond to life changes. Choices A, B, and C are not the main limitations of the RLCQ. Specific illnesses not being identified or numerical values being randomly assigned do not directly impact the personal perception of life events. Additionally, viewing stress as only a physiological response is not the primary limitation, as stress encompasses psychological and emotional components as well.

4. When discussing discipline with the mother of a 4-year-old child, which should the nurse include?

Correct answer: A

Rationale: Consistent parental control is crucial for effective discipline, providing clear expectations and consequences for behavior.

5. An 80-year-old patient with a history of renal insufficiency was recently started on cimetidine. Which assessment finding indicates that the patient may be experiencing an adverse effect of the medication?

Correct answer: B

Rationale: The correct answer is B: New onset disorientation to time and place. Cimetidine can cause adverse effects on the CNS system, especially in elderly patients with renal or hepatic impairment. This may manifest as confusion, hallucinations, lethargy, restlessness, or seizures. Pain with urination (choice A) is not typically associated with cimetidine use, and HR changes (choice C) are more likely related to other factors. Choice D is not a valid option.

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