ATI RN
Pathophysiology Final Exam
1. A public health nurse is responsible for the administration of numerous immunizations. Which of the following guidelines regarding anaphylaxis should the nurse adhere to?
- A. The patient should be observed for anaphylaxis for 1 minute after administration.
- B. The patient should be observed for anaphylaxis for 5 minutes after administration.
- C. The patient should be observed for anaphylaxis for 30 minutes after administration.
- D. The patient should be observed for anaphylaxis for 90 minutes after administration.
Correct answer: C
Rationale: The correct answer is C: 'The patient should be observed for anaphylaxis for 30 minutes after administration.' This is because anaphylaxis can occur within minutes of administration of an immunization. By observing the patient for 30 minutes, the nurse can promptly identify and manage any signs of anaphylaxis. Choices A, B, and D are incorrect as they suggest shorter or longer observation periods, which may not be sufficient to detect and respond to anaphylaxis in a timely manner.
2. A hospice nurse is providing teaching to a client who has a new diagnosis of a terminal illness and her family. Which of the following statements should the nurse include in the teaching?
- A. Hospice care focuses on providing comfort and symptom management.
- B. The provider will coordinate your health care needs while in hospice.
- C. You do not need to choose a family caregiver before being admitted into a hospice facility.
- D. Hospice care continues to help families with grief after a death occurs.
Correct answer: D
Rationale: The correct answer is D because hospice care provides ongoing support to families with grief even after a patient's death. Choice A is incorrect because hospice care focuses on providing comfort and symptom management rather than disease treatment and rehabilitation. Choice B is incorrect as the statement does not accurately reflect the role of a hospice provider. Choice C is incorrect; a family caregiver is not a prerequisite for admission into a hospice facility.
3. A client has global aphasia affecting both receptive and expressive language abilities. Which intervention should NOT be included in the client's care plan?
- A. Speak to the client at a slower rate.
- B. Assist the client in using flash cards with pictures.
- C. Speak to the client in a loud voice.
- D. Give instructions one step at a time.
Correct answer: C: Speak to the client in a loud voice.
Rationale: Individuals with global aphasia have difficulty understanding and expressing language. Speaking loudly may not improve comprehension and can be perceived as aggressive. Therefore, it is important not to speak loudly to a client with global aphasia. Speaking at a slower rate, using visual aids like flash cards, and breaking down instructions into simple steps can facilitate communication and understanding for the client.
4. While reviewing a client's chart, a nurse notices a discrepancy in the medication record. What should the nurse do?
- A. Correct the discrepancy and document the correction.
- B. Report the discrepancy to the nurse manager.
- C. Ignore the discrepancy assuming it is a clerical error.
- D. Discuss the discrepancy with the client and adjust the records.
Correct answer: B
Rationale: Reporting medication discrepancies to the nurse manager is crucial to ensure patient safety and proper follow-up. The nurse manager is responsible for addressing medication errors and implementing necessary corrective actions. Choice A is incorrect because simply correcting the discrepancy without reporting it may lead to potential harm to the patient and violates professional standards. Choice C is incorrect as ignoring the discrepancy increases the risk of medication errors going unresolved. Choice D is incorrect because discussing the discrepancy with the client before verifying the accuracy of the record can cause confusion and compromise patient safety.
5. After signing an informed consent form, a client states, 'I have changed my mind and do not want to have the procedure.' Which of the following actions should the nurse take?
- A. Suggest that family members discuss the importance of the surgery with the client
- B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure
- C. Document the risks of refusing the procedure in the client's medical record
- D. Discuss the benefits of the procedure with the client
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to notify the surgeon that the client wishes to withdraw informed consent for the procedure. This ensures that the client's right to refuse treatment is respected. Choice A is incorrect because involving family members in this decision could violate the client's autonomy. Choice C is incorrect as it does not address the immediate need to respect the client's decision. Choice D is also incorrect as the client has clearly stated their refusal of the procedure.
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