ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. What is the priority intervention for the nurse to enhance meeting the psychosocial needs of a client on transmission-based precautions?
- A. Allow the client sleep to build stamina
- B. Provide the client with diversional activities
- C. Maintain a six-foot distance from the client
- D. Provide a timeframe for the isolation
Correct answer: Provide the client with diversional activities
Rationale:
2. A client has a new prescription for furosemide. Which of the following instructions should the nurse include during discharge teaching?
- A. Avoid prolonged exposure to sunlight.
- B. Take this medication with a meal.
- C. Increase your intake of potassium-rich foods.
- D. Limit your fluid intake to 1 liter per day.
Correct answer: C
Rationale: The correct instruction for a client taking furosemide is to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss, so increasing potassium-rich foods helps prevent hypokalemia. Choice A, avoiding prolonged exposure to sunlight, is not directly related to furosemide use. Choice B, taking the medication with a meal, is not a specific requirement for furosemide administration. Choice D, limiting fluid intake to 1 liter per day, is not the correct advice as furosemide is a diuretic that often requires increased fluid intake to prevent dehydration.
3. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?
- A. Notify the provider.
- B. Administer heparin via IV infusion.
- C. Administer oxygen therapy.
- D. Obtain a spiral CT scan.
Correct answer: C: Administer oxygen therapy.
Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.
4. A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
- A. Deficits in the right visual field
- B. Unable to discriminate words and letters
- C. Motor retardation
- D. Poor impulse control
Correct answer: D
Rationale: The correct answer is D, poor impulse control. Right hemisphere strokes commonly affect judgment and safety awareness, leading to poor impulse control. Choices A, B, and C are incorrect for this scenario. Deficits in the right visual field are associated with left hemisphere strokes, while the inability to discriminate words and letters is typically seen with left hemisphere damage. Motor retardation is more common in strokes affecting the motor areas of the brain, not specifically related to right hemisphere strokes.
5. A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy?
- A. Tenting of skin on the back of the hand
- B. Increased urine osmolarity
- C. Weight loss of 10 pounds
- D. Pulse rate of 115 beats/min
Correct answer: Pulse rate of 115 beats/min
Rationale: The correct answer is the pulse rate of 115 beats/min. A rapid pulse rate is a sign of compensatory mechanisms in response to dehydration, indicating that the body is trying to deliver oxygen more efficiently. Oxygen therapy may be needed to support the increased oxygen demand. Tenting of skin on the back of the hand is a classic sign of dehydration due to decreased skin turgor. Increased urine osmolarity and weight loss are also indicators of dehydration, but they do not directly suggest a need for oxygen therapy.
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