ATI LPN
ATI Proctored Community Health
1. At what age is the first dose of the MMR vaccine typically administered to a child?
- A. At birth
- B. 6 months
- C. 12 months
- D. 18 months
Correct answer: C
Rationale: The first dose of the MMR vaccine is typically administered to a child at 12 months of age to provide protection against measles, mumps, and rubella. Administering the vaccine at this age ensures that the child's immune system is developed enough to generate a protective response to the vaccine.
2. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care?
- A. Monitor the client's temperature every 4 hours
- B. Monitor blood glucose levels every 6 hours
- C. Administer insulin as prescribed
- D. Monitor daily fluid intake
Correct answer: B
Rationale: Corrected Rationale: Monitoring blood glucose levels is crucial in clients receiving TPN because the solution has a high glucose content. This monitoring helps prevent hyperglycemia and allows for timely adjustments in the TPN formulation if needed. Monitoring the client's temperature (Choice A) is not directly related to TPN administration. Administering insulin (Choice C) should be based on blood glucose levels and the healthcare provider's orders; it is not a standard intervention for all clients on TPN. Monitoring daily fluid intake (Choice D) is important for overall fluid balance but is not as critical as monitoring blood glucose levels specifically for clients on TPN.
3. The nurse is preparing to administer vitamin K to a newborn. The mother asks why this injection is necessary. What is the nurse's best response?
- A. It helps the baby's liver function properly.
- B. It prevents bleeding disorders in the newborn.
- C. It boosts the baby's immune system.
- D. It promotes the baby's growth and development.
Correct answer: B
Rationale: The correct answer is B. Vitamin K is administered to newborns to prevent bleeding disorders since they have low levels of vitamin K, which is essential for blood clotting. By providing this injection, the nurse ensures that the newborn has an adequate supply of vitamin K to support proper blood clotting and prevent potential bleeding complications. Choices A, C, and D are incorrect because vitamin K's primary role in newborns is related to blood clotting and preventing bleeding, not liver function, immune system, or growth and development.
4. When teaching a client with a new prescription for spironolactone, which instruction should the nurse include?
- A. Increase your intake of potassium-rich foods.
- B. Avoid consuming grapefruit juice.
- C. Take the medication with food.
- D. Monitor for signs of hyperkalemia.
Correct answer: D
Rationale: The correct answer is to instruct the client to monitor for signs of hyperkalemia when taking spironolactone since it is a potassium-sparing diuretic. Hyperkalemia is a potential adverse effect due to the medication's mechanism of action. Advising the client to increase potassium-rich foods (Choice A) would be incorrect as it can further elevate potassium levels, which could lead to hyperkalemia. Avoiding grapefruit juice (Choice B) is not directly related to spironolactone use. Though taking the medication with food (Choice C) can help reduce gastrointestinal upset, it is not the most critical instruction when initiating spironolactone therapy.
5. Child protective services have removed 10-year-old Christopher from his parents’ home due to neglect. Christopher reveals to the nurse that he considers the woman next door his “nice” mom, that he loves school, and gets above-average grades. The strongest explanation for this response is:
- A. Temperament
- B. Genetic factors
- C. Resilience
- D. Paradoxical effects of neglect
Correct answer: C
Rationale: Resilience is the ability to adapt well despite adversity, which is demonstrated by Christopher's positive relationships and school performance. Despite the challenging situation of being removed from his parents' home, Christopher's ability to form a positive bond with the neighbor, enjoy school, and excel academically showcases his resilience in coping with the circumstances.
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