ATI RN
Multi Dimensional Care | Final Exam
1. Which nonpharmacological intervention does not help reduce edema?
- A. Heat therapy
- B. Passive range of motion (PROM)
- C. Elevation of the extremity
- D. Cold therapy
Correct answer: A
Rationale: The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.
2. A client is prescribed gentamicin for an infection. Which finding indicates a potential adverse reaction to the medication?
- A. Blood pressure 160/90 mm Hg
- B. Presence of red blood cells in the urine
- C. Urine output of 35 mL/hr
- D. Respiratory rate of 22/min
Correct answer: B
Rationale: The presence of red blood cells in the urine is a significant finding that can indicate nephrotoxicity, a potential adverse effect of gentamicin. Nephrotoxicity can lead to kidney damage, and monitoring for this adverse reaction is crucial during gentamicin therapy. Elevated blood pressure (Choice A) is not typically associated with gentamicin adverse reactions. Decreased urine output (Choice C) may suggest kidney impairment but is not as specific as the presence of red blood cells in the urine. Respiratory rate (Choice D) is not directly related to potential adverse reactions to gentamicin.
3. When caring for a client receiving treatment with irinotecan, which of the following findings should the nurse monitor?
- A. Diarrhea
- B. Hypertension
- C. Ototoxicity
- D. Neutropenia
Correct answer: A
Rationale: The correct answer is diarrhea. Irinotecan commonly causes diarrhea as an adverse effect due to its impact on the gastrointestinal tract. Monitoring for diarrhea is essential to prevent dehydration and manage this side effect effectively. Choices B, C, and D are incorrect as hypertension, ototoxicity, and neutropenia are not commonly associated with irinotecan therapy.
4. A client who has been having frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse add to the client's plan of care?
- A. Apply restraints
- B. Use soft wristbands
- C. Wrap blankets around side rails
- D. Administer sedatives
Correct answer: C
Rationale: The correct action the nurse should add to the client's plan of care is to wrap blankets around side rails. This helps prevent injury during seizures by providing a cushioned surface against the hard rails. Applying restraints (Choice A) is not recommended as it can cause harm during a seizure. Using soft wristbands (Choice B) may not provide adequate protection against injury. Administering sedatives (Choice D) is not typically indicated for managing tonic-clonic seizures as they require specific anti-seizure medications.
5. Which of the following processes does not help maintain the life of an individual organism?
- A. Responsiveness
- B. Movement
- C. Reproduction
- D. Respiration
Correct answer: C: Reproduction
Rationale: Reproduction is the correct answer because it is not essential for maintaining the life of an individual organism. While reproduction is crucial for the continuation of a species, it is not directly related to the survival or maintenance of an individual organism. Responsiveness allows an organism to react to stimuli, movement helps in obtaining resources and avoiding danger, and respiration provides the necessary energy for life processes. Therefore, reproduction is the process that does not directly contribute to maintaining the life of an individual organism.
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