a patient in the emergency department reports taking sildenafil viagra and nitroglycerin 1 hr before sexual activity which finding should the nurse im
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Nursing Elites

ATI RN

ATI Pediatric Proctored Exam

1. A patient in the emergency department reports taking sildenafil (Viagra) and nitroglycerin 1 hr before sexual activity. Which finding should the nurse immediately report to the physician?

Correct answer: D

Rationale: The correct answer is D: BP of 70/50. When sildenafil (Viagra) is taken with nitroglycerin, it can cause severe hypotension that is unresponsive to treatment. The combination of these medications can lead to a dangerous drop in blood pressure. It is crucial to immediately report hypotension in this scenario as it poses a significant risk to the patient's life. It is recommended to allow at least 24 hours to elapse between the last dose of sildenafil and nitroglycerin to prevent such adverse effects. The other vital signs and lab values may be abnormal but do not have the immediate life-threatening implications that severe hypotension does in this context.

2. The healthcare provider is assessing abdominal girth for a pediatric client who presents with abdominal distension. Which nursing action is appropriate?

Correct answer: D

Rationale: Measuring the girth around the largest portion of the abdomen ensures accurate assessment and tracking of abdominal distension. This method provides a more comprehensive measurement and helps healthcare providers monitor changes effectively.

3. In which frame of reference do activities involve responses to movement, balance, weight bearing, and tactile activities?

Correct answer: B

Rationale: Ayres' sensory integration focuses on activities that target responses to movement, balance, weight bearing, and tactile stimuli to improve sensory processing and integration. This approach aims to address sensory challenges through structured activities to enhance overall function and participation. Motor control/motor learning (Choice A) deals with the control and coordination of voluntary movements. Neurodevelopmental treatment (Choice C) focuses on facilitating normal movement patterns and postural control. Developmental (Choice D) refers to the natural sequence of growth and development in children.

4. When teaching a parent of a toddler with congenital heart disease, which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction for a parent of a toddler with congenital heart disease is to offer small, frequent meals. This recommendation helps reduce the cardiac workload on the child's heart and supports easier digestion and nutrient absorption, promoting the child's overall health. Limiting physical activity (choice B) may be necessary but is not the priority in this case. While offering a low-sodium diet (choice C) can be beneficial, it is not the most critical instruction. Monitoring the toddler's intake and output (choice D) is important but not as essential as providing small, frequent meals to support the child's heart health.

5. A parent of an infant with congenital hypothyroidism is receiving teaching from a nurse. Which of the following statements should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D. Congenital hypothyroidism requires lifelong medication to manage the condition effectively. The nurse should emphasize to the parent that their child will need to take the medication for life to ensure proper thyroid hormone levels and prevent complications associated with hypothyroidism.

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