which of the following action would be of highest priority with regards to the external shunt
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Nursing Elites

ATI RN

ATI Nutrition Practice Test A 2019

1. Which of the following actions would be of highest priority with regards to the external shunt?

Correct answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

2. A breastfeeding mother complains that she missed her son's last two feedings and now her breasts have become full, hard, and uncomfortable. This condition is known as _____.

Correct answer: B

Rationale: Engorgement occurs when the breasts become overly full, leading to discomfort and sometimes difficulty with latching. It can be relieved by feeding or expressing milk. Mastitis, choice A, is characterized by breast inflammation usually caused by an infection. Letdown, choice C, refers to the release of milk from the breast. Galactorrhea, choice D, is the spontaneous flow of milk from the breast unassociated with childbirth or nursing.

3. Which of the following ethical principles refers to the duty to do good?

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

4. It is not a legally binding document but nevertheless, Very important in caring for the patients.

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. Which of the following statements about Z-Track technique is false?

Correct answer: B

Rationale: The Z-Track technique is aimed at preventing medication leakage into the surrounding tissues by sealing the medication in the muscle, not by creating a Zig-Zag pattern. Choice A is correct as Z-Track injections help prevent irritation. Choice C is correct as it accurately describes how the technique works. Choice D is also correct as the Z-Track technique is commonly used when administering Parenteral Iron to prevent staining and irritation of the surrounding tissues.

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