ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?
- A. Amount
- B. Consistency
- C. Heat
- D. Odor
Correct answer: Heat
Rationale:
2. During blood administration, what is essential for the nurse to do in order to carefully monitor for adverse reactions?
- A. Stay with the client for the first 15 minutes of blood administration
- B. Stay with the client for the entire period of blood administration
- C. Run the infusion at a faster rate during the first 15 minutes
- D. Inform the client to notify the staff immediately for any adverse reaction
Correct answer: A
Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.
3. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?
- A. Increase the I.V. infusion rate.
- B. Use diversion activities.
- C. Provide frequent mouth care.
- D. Give ice chips every 15 minutes.
Correct answer: C
Rationale: Providing frequent mouth care is the priority for a patient with peritonitis who is NPO and complaining of thirst.
4. When educating a parent of an infant with a new prescription for digoxin, which instruction should the nurse provide?
- A. Repeat the dose if the infant vomits.
- B. Mix the medication with food.
- C. Give the medication with meals.
- D. Monitor the infant's heart rate prior to administering the medication.
Correct answer: D
Rationale: The correct answer is D: 'Monitor the infant's heart rate prior to administering the medication.' It is crucial for the nurse to monitor the infant's heart rate before giving digoxin to identify any signs of digoxin toxicity early. Heart rate assessment helps in detecting and preventing potential complications associated with digoxin use. Choices A, B, and C are incorrect. Repeating the dose if the infant vomits can lead to overdose, mixing the medication with food may alter its absorption, and giving the medication with meals can affect its effectiveness. Therefore, the priority is to monitor the infant's heart rate to ensure safe administration of digoxin.
5. A client has a new prescription for alendronate to treat osteoporosis. Which of the following instructions should be included?
- A. Take the medication with food to reduce nausea.
- B. Take the medication first thing in the morning on an empty stomach.
- C. Take the medication with a full glass of milk.
- D. Take the medication with meals.
Correct answer: B
Rationale: Alendronate should be taken first thing in the morning on an empty stomach to maximize absorption. Taking it with food, milk, or meals can reduce its effectiveness by impairing absorption. Therefore, advising the client to take it on an empty stomach is crucial for optimal therapeutic outcomes.
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