ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. By providing measures to reduce skin breakdown, how does the nurse break the chain of infection?
- A. Sterilizing the area to reduce the reservoir risk
- B. Maintaining the integrity of a portal of entry
- C. Creating a reservoir to decrease the risk of infection
- D. Creating a susceptible host
Correct answer: Maintaining the integrity of a portal of entry
Rationale:
2. A client reports intimate partner violence to a nurse. What is the nurse's priority action?
- A. Develop a safety plan with the client.
- B. Refer the client to a community support group.
- C. Determine if the client has any injuries.
- D. Ensure the client has access to legal services.
Correct answer: A
Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.
3. Riboflavin
- A. Vitamin B1
- B. Vitamin B2
- C. Vitamin B3
- D. Vitamin B12
Correct answer: B
Rationale: Riboflavin is also known as Vitamin B2, which is important for energy production and the metabolism of fats, drugs, and steroids.
4. A hospitalized client receiving IV heparin for a deep-vein thrombosis begins vomiting blood. After the heparin has been stopped, which of the following medications should the nurse prepare to administer?
- A. Vitamin K1
- B. Atropine
- C. Protamine
- D. Calcium gluconate
Correct answer: C
Rationale: In this scenario, the client is experiencing a serious complication of heparin therapy, likely due to heparin-induced thrombocytopenia. Protamine is the antidote for heparin and can reverse its anticoagulant effects. It is essential to administer protamine promptly to counteract the effects of heparin and manage the bleeding. Vitamin K1 is used to reverse the effects of warfarin, not heparin. Atropine is used to treat bradycardia or some types of poisoning. Calcium gluconate is used to manage hyperkalemia or calcium channel blocker toxicity, not to reverse heparin's effects.
5. A client has a new prescription for Clozapine. Which of the following statements should the nurse include in the teaching?
- A. You should have a high-carbohydrate snack between meals and at bedtime.
- B. You are likely to develop hand tremors if you take this medication for a long period of time.
- C. You may experience temporary numbness of your mouth after each dose.
- D. You should have your white blood cell count monitored every week.
Correct answer: D
Rationale: Clozapine carries a risk for fatal agranulocytosis. To monitor for this serious adverse effect, it is crucial to check the client's white blood cell count weekly while they are on clozapine therapy.
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