ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by health care workers?
- A. Wearing a mask within three feet of the client
- B. Intentional
- C. Using standard precautions
- D. Proliferative
Correct answer: Using standard precautions
Rationale:
2. A nurse is caring for a client who is 1 hour postpartum. Which of the following findings should the nurse report to the provider?
- A. Fundus firm and at the umbilicus.
- B. Heart rate 80/min.
- C. Blood pressure 130/78 mm Hg.
- D. A constant trickle of bright red blood from the vagina.
Correct answer: D
Rationale: After childbirth, it is normal for the fundus to be firm and at the level of the umbilicus, heart rate to be around 80/min, and blood pressure to be slightly elevated. However, a constant trickle of bright red blood from the vagina is concerning as it could indicate postpartum hemorrhage. This finding should be reported promptly to the healthcare provider for further evaluation and intervention. Choices A, B, and C are within expected postpartum parameters and do not indicate an immediate need for intervention.
3. A nurse is reviewing blood glucose values for a client who is at risk for Diabetes Mellitus. Which of the following findings should the nurse report to the provider?
- A. 2 hr glucose tolerance test level 150 mg/dL
- B. Fasting blood glucose 70 mg
- C. Glycosylated hemoglobin 5%
- D. Casual blood glucose 90 mg/dL
Correct answer: A
Rationale: A 2-hour glucose tolerance test level of 150 mg/dL is above the normal range and should be reported to the provider as it indicates impaired glucose tolerance.
4. A client has a new prescription for Warfarin. Which of the following statements by the client indicates a need for further teaching?
- A. I will avoid eating large amounts of green leafy vegetables.
- B. I will take my medication at the same time every day.
- C. I will increase my intake of foods high in potassium.
- D. I will report any signs of bleeding to my provider.
Correct answer: C
Rationale: The correct answer is C because Warfarin interacts with vitamin K, not potassium. Therefore, the client needs to be cautious with foods high in vitamin K, such as green leafy vegetables, rather than foods high in potassium. Choices A, B, and D are correct statements regarding Warfarin therapy and do not indicate a need for further teaching.
5. After a subtotal gastrectomy, care of the client’s nasogastric tube and drainage system should include which of the following nursing interventions?
- A. Irrigate the tube with 30 ml of sterile water every hour, if needed.
- B. Reposition the tube if it is not draining well
- C. Monitor the client for N/V, and abdominal distention
- D. Turn the machine to high suction of the drainage is sluggish on low suction.
Correct answer: C
Rationale: Monitoring the client for nausea, vomiting, and abdominal distention is crucial for ensuring proper functioning of the nasogastric tube and drainage system.
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