ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. When providing a routine bed bath, what action does the nurse complete first?
- A. Cleanse the client’s feet
- B. Cleanse the client’s hands
- C. Cleanse the client’s perineal area
- D. Cleanse the client’s face
Correct answer: Cleanse the client’s face
Rationale:
2. What should be the priority action when a patient is admitted with chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Obtain IV access
- C. Check cardiac enzymes
- D. Administer aspirin
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action in treating chest pain associated with acute coronary syndrome as it helps to dilate blood vessels, improve blood flow to the heart, and reduce cardiac tissue damage. Administering nitroglycerin is crucial in managing the symptoms and potential complications of acute coronary syndrome. Obtaining IV access (Choice B) is important for administering medications and fluids but does not address the immediate symptom of chest pain. Checking cardiac enzymes (Choice C) and administering aspirin (Choice D) are essential steps in the management of acute coronary syndrome, but they should follow the administration of nitroglycerin to address the immediate symptom and improve blood flow to the heart.
3. After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client’s vital signs. What phase of the nursing process is being implemented by the nurse?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
Correct answer: A
Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process. Choice B, 'Diagnosis,' would involve analyzing the collected data to identify the client's health problems. Choice C, 'Planning,' would be developing a plan of care based on the assessment findings. Choice D, 'Implementation,' is the phase where the nurse carries out the plan of care developed during the planning phase.
4. . A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
- A. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.
- B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance
- C. The kidneys react rapidly to compensate for imbalances in the body
- D. The kidneys regulate the bicarbonate level in the intracellular fluid.
Correct answer: The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance
Rationale:
5. A patient is receiving glucocorticoids for the treatment of rheumatoid arthritis. The patient complains of having a headache. Which ordered medication should the nurse administer?
- A. Aspirin
- B. Acetaminophen
- C. Ibuprofen
- D. Naproxen Sodium (Aleve)
Correct answer: B
Rationale: When a patient is already receiving glucocorticoids for rheumatoid arthritis and complains of a headache, it is essential to consider the potential interactions and side effects of additional medications. Aspirin and NSAIDs like ibuprofen and naproxen sodium can increase the risk of gastrointestinal irritation and ulceration when used concurrently with glucocorticoids. Acetaminophen is a safer choice in this scenario for managing the patient's headache without exacerbating the gastrointestinal issues associated with the use of glucocorticoids. Acetaminophen does not have the same gastrointestinal side effects as aspirin, ibuprofen, or naproxen sodium, making it the most appropriate option for headache relief in this case.
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