ATI NUR 5308 RN Fundamental Exam with Rationales

ATI NUR 5308 RN Fundamental Exam with Rationales  A nurse is preparing to administer diphenhydramine20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which of the following images shows the correct # of mL the nurse should administer? (Round the answer to the nearest whole number.) Click on the syringe that has 8 mL of med. 20 mg x (5mL/12.5mg) = 8 mL  A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80 mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much cefoxitin should the nurse administer with each dose?(Round the answer to the nearest whole number. Use a leading zero if it applies .Do not use a trailing zero.) ◗ So it says each dose for the final answer ,but wear e given 80 mg/kg/day. ◗ 80 x 20 = 1600 / 4 (dose is given every 6 hours a day) = 400 mg ◗ Rationale: 80 mg x20 kg = 1,600 1,600/4 x day (q6h) = 400 mg  A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?  Label the pump with a defective equipment sticker.  Unplug the pump.  Obtain a replacement pump.  Notified the biomedical department to fix the pump. ◗ Rationale: Prioritization question .YOU WILL FIRST UNPLUG the IV pump to avoid causing a fire.  A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound healing?  Serum albumin 3 g/dL  Total lymphocytecount2400 mm3  HCT42%  HGB 16g/dL ◗ Rationale: Albumin in low. Normal range is 3.5 to 5.5 g/ dL. Low albumin places the client at risk forpoor wound healing. The other lab values are within normal limits.  A nurse is caring for a client who is scheduled to havehis alanine aminotransferase(ALT) level checked. Theclient asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?  “This test will indicate if you are at risk for developing blood clots  “This test will determine if your heart is performing properly”  “This test will provide information about the function of your liver” ◗ Rationale: ALT test measures amount of enzyme in blood. ALT mainly found in liver ◗ Rationale: Leadership 7.0. ALT and AST measure you liver function. Creatinine and BUN measure your kidney function  “This test is used to check how your kidneys are working” .  A nurse is caring for a client who has a prescription for morphine 5mg IM accidentally administers the whole 10 mg from the single-dosevial. Which of the following actions should the nurse take first?  Notify the client’s provider.  Report the incident to the pharmacy.  Complete an incident report.  Measure the client’s respiratory rate. ◗ Rationale: morphine OD = pulmonary edema fills lungs w/ fluid leading cause of death for OD ◗ Rationale: Morphine can causerespiratorydepressionif giventoo much. Alsoyou should ALWAYSASSESS the patient first when a med error is performed to make sure med error doesn’t put the client’shealthinrisk.  A nurseis preparing to check a client's blood pressure. Which of the following actions should the nurse take? Chapter 27 Vitals signs page 244  Apply the cuff above the client’s antecubital fossa.  Useacuff with a width that is about 60% of theclient's arm circumference. - width of the cuff should be40 % of arm circumference  How the clients sit with his arm resting above the level of his heart. - MUST BE AT HEART LEVEL  Releasethe pressure on theclient's arm 5 to 6 mm per second. -pressure release should notbe morethan2to 3 mm hg per second ◗ Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the pressure no faster than2to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) abovethe antecubital space with thebrachial artery inline with the marking onthe cuff. Apply the BP cuff 2.5 cm (1 in) above the antecubital spacewith the brachial artery in line with the marking on the cuff.  A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriateaction for the nurse to take? Chapter 53 Airway management page 563  Hold thesuction catheter with theclean non-dominanthand.  Apply suctioning for 20 to 30 seconds. - 10 -15 seconds is the maximum.  Placethe catheter inalocation that is clean and dry for later usenew line. - NEVER EVER REUSETHE SUCTION CATHETER . you throw it away after being used.  Use surgicalasepsis when performing the procedure. - book say medical asepsis which is maybethe same thing . ◗ Rationale: steriletechnique for trachea ◗ Rationale: ATI FUNDA. PG. 316 Usesurgical asepsis for all types of suctioning. Nolonger than 10-15seconds to avoid hypoxemia  A nurse is documenting client care. Which of the following abbreviations should the nurse use?ati book wasnot thorough soi had to go ondifferent sites for charts - not confident with this, pleasedouble check.  “SS” for sliding scale  “BRP” for bathroom privileges  “OJ” for orange juice- do not  “SQ” for subcutaneous-donot  A nurseis collecting A blood pressure reading from a client who is sitting in a chair period thenursedetermines that the clients BP is 158/96 mmhg. which of thefollowing actions should the nursetake?  Ensurethat the widthof the BP cuff is 50% of the client’s upper arm circumference. It says 40%  Repositiontheclient Supineandrecheckher BP. BP. → ORTHOSTATIC HYPOTENSION  Recheck the clients BP and her otherarm forcomparison.  Request that another nursecheck the the clients BP in 30 minutes. → 15 minutes  A nurse is caring for a client who has left lower atelectasis. in which of the following positions should thenurseplace the client for postural drainage? Chapter 53 Airway Management page 562  Supineand low-Fowler's position  Right lateral in Trendelenburg position  Side lying with theright sideof the chest elevated  Prone with pillows under the extremities  A nurseis receiving the prescription for a client who is experiencing dysphagia following a stroke. Whichof the following prescriptions should the nurse clarify?  Dietitian consult  Speech therapy referral  Oral suction at thebedside  Clear liquids- liquids must be THICK. Clear liquids can cause aspiration ◗ Rationale: ATI MS. Pg. 83 food levels for dysphagia include pureed, mechanically altered,advanced/mechanically soft