the nurse is caring for clients on a medical floor which client will the nurse assess first

ATI RN

ATI RN Custom Exams Set 4

1. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

A. The client with an abdominal aortic aneurysm who is constipated
B. The client on bed rest who ambulated to the bathroom
C. The client with essential hypertension who has epistaxis and a headache
D. The client with arterial occlusive disease who has a decreased pedal pulse

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis, requiring immediate intervention. Option A is incorrect as constipation in a client with an abdominal aortic aneurysm, though important, does not indicate an immediate need for assessment. Option B, a client on bed rest who ambulated to the bathroom, does not present with urgent signs or symptoms requiring immediate assessment. Option D, a client with arterial occlusive disease and a decreased pedal pulse, needs attention but is not the priority compared to a hypertensive crisis with epistaxis and headache.

2. Under the health services support area concept, how is the medical care under the MEDCOM divided?

A. Six geographical regions of the United States with command authority in each region
B. Five levels of health service support, each providing different levels of health care services
C. Primary and secondary health care regions, each containing a MEDDAC or MEDCEN
D. Eight geographical areas of responsibility designated as health services support regions, each of which is subdivided into two or more health service areas

Correct answer: D

Rationale: The correct answer is D. Under the health services support area concept, the medical care under the MEDCOM is divided into eight geographical areas of responsibility designated as health services support regions, each of which is further subdivided into two or more health service areas. This structure allows for a more organized and efficient delivery of medical care across different regions. Choices A, B, and C are incorrect because they do not accurately describe how medical care under the MEDCOM is divided according to the concept of health services support areas.

3. Warfarin (Coumadin) is an anticoagulant and interferes with the action of:

A. Platelets
B. Vitamin K
C. Calcium
D. Vitamin B12

Correct answer: B

Rationale: The correct answer is B: Vitamin K. Warfarin inhibits the action of vitamin K, which is essential for blood clotting. By interfering with the production of certain clotting factors, warfarin helps prevent blood clots. Choices A, C, and D are incorrect because warfarin primarily affects the vitamin K-dependent clotting factors and not platelets, calcium, or vitamin B12.

4. When is Aspirin most effective when taken?

A. On an empty stomach with cold water
B. On a full stomach after a meal
C. With a glass of fruit juice
D. First thing in the morning

Correct answer: A

Rationale: Aspirin is best absorbed on an empty stomach to maximize its effectiveness. Taking it with cold water helps to enhance absorption. Choice B is incorrect as taking aspirin on a full stomach may reduce its absorption. Choice C is incorrect as fruit juice can sometimes interact with medications. Choice D is incorrect as taking aspirin first thing in the morning may not optimize its absorption.

5. The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

A. The nursing assistant aspirates and measures the amount of gastric aspirate
B. The nursing assistant elevates the head of the client’s bed 30 degrees
C. The nursing assistant warms the formula to room temperature
D. B, C

Correct answer: D

Rationale: The correct answer is D because elevating the head of the bed reduces the risk of aspiration, and warming the formula to room temperature helps prevent discomfort and complications. Choice A is incorrect as only licensed healthcare professionals should aspirate and measure the amount of gastric aspirate. Choice B is correct as it helps prevent aspiration. Choice C is correct as warming the formula can prevent discomfort.