what is the first intervention for a patient who is experiencing anaphylactic shock
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. What is the first intervention for a patient experiencing anaphylactic shock?

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for anaphylactic shock as it helps reverse the severe allergic reaction by constricting blood vessels, increasing heart rate, and opening airways for improved breathing. Oxygen (Choice B) can be administered after epinephrine to support oxygenation. Corticosteroids (Choice C) may be used to prevent a biphasic reaction but are not the initial intervention. Antihistamines (Choice D) can help with itching and hives but do not address the life-threatening symptoms of anaphylaxis.

2. A patient is receiving radiation therapy. Which of the following skin care instructions should the nurse provide?

Correct answer: D

Rationale: Correct Answer: The nurse should instruct the patient to wear loose clothing over the radiation site. This helps prevent skin irritation and promotes healing by reducing friction and irritation on the treated area.\nChoice A is incorrect because applying a heating pad can further irritate the skin that is already sensitive due to radiation therapy.\nChoice B is incorrect because scented lotions may contain ingredients that could further irritate the skin.\nChoice C is incorrect because covering the radiation site with a bandage can trap moisture and lead to skin breakdown, increasing the risk of infection.

3. A healthcare provider is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which finding should the healthcare provider identify as a contraindication to the administration of clozapine?

Correct answer: D

Rationale: The correct answer is D: a low WBC count. Clozapine can suppress bone marrow function, leading to a decreased white blood cell count. This condition, known as agranulocytosis, increases the risk of severe infections. Monitoring WBC counts is essential during clozapine therapy. Choices A, B, and C are within normal ranges and are not contraindications for administering clozapine.

4. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Monitoring blood glucose levels before meals and at bedtime is crucial for managing type 2 diabetes mellitus. Option A is incorrect because limiting protein intake is not a primary focus for diabetes management. Option B is unrelated to diabetes management and focuses on pain relief. Option D mentions reducing carbohydrate intake, which is a common dietary recommendation for managing blood sugar levels, but it is not as specific as monitoring blood glucose levels at key times.

5. A nurse is providing dietary teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

Correct answer: C

Rationale: Clients taking warfarin should avoid foods high in vitamin K, as it can interfere with the effectiveness of the medication.

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