ATI 2500 NURS TRIAL EXAM-FINAL

A nurse should include which discharge instruction for clients receiving tricyclic antidepressants? You Selected: Restrict fluid and sodium intake while using this medication. Correct response: Don't consume alcohol while using this medication. Explanation: Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry mouth and blurred vision are normal adverse effects of tricyclic antidepressants. Fluid and sodium intake must be monitored during lithium treatment, not during treatment with tricyclic antidepressants. Safe use of tricyclic antidepressants during pregnancy and breast-feeding hasn't been established. Remediation: Amitriptyline hydrochloride Clomipramine hydrochloride Question 3 See full question The nurse prepares to administer promethazine 35 mg IM as prescribed PRN for a client with cholecystitis who has nausea. The ampule label reads that the medication is available in 25 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place. Your Response: 0.7 Correct response: 1.4 Explanation: The following formula is used to calculate the correct dosage: 35 mg/X = 25 mg/1 mL X = (35/25) mL X = 1.4 mL. Question 4 See full question Levothyroxine 0.2 mg orally has been prescribed for a client diagnosed with hypothyroidism. The nurse has available 0.05-mg tablets. How many tablets should the nurse prepare to give the client? You Selected: two tablets Correct response: four tablets Explanation: 0.2 mg/x tablet = 0.05 mg/1 tablet. x = 4 tablets. Remediation: Levothyroxine sodium Question 5 See full question What is the nurse’s priority intervention for a toddler who has just had a hip-spica cast applied? You Selected: Assess sensation, circulation, and motion of the child’s feet and toes Correct response: Assess sensation, circulation, and motion of the child’s feet and toes Explanation: Assessing sensation, circulation, and motion is necessary in all children with a cast. Fluids should be encouraged, and careful diapering and padding will keep the child’s cast dry. Discharge instructions are not a priority, but should be shared at a later time. Children experiencing pain should receive medication as needed. Remediation: Cast assessment and management, pediatric Casting, pediatric Question 6 See full question A child requires IV fluids to infuse at 27 ml/hr. The tubing delivers 60 gtts/ml. How many gtts/min should the nurse count to ensure that the fluid is safely infusing? You Selected: 27 gtts/min Correct response: 27 gtts/min Explanation: The nurse should count 27 gtts/min. 27 ml/h x 60 gtts/ml ÷ 60 min/h = 27 gtts/min Remediation: IV infusion, dose and flow rate calculations Question 7 See full question Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic, and difficult to feed. To maintain the infant's nutritional status, which action would be most appropriate? You Selected: Give the infant small, frequent feedings. Correct response: Give the infant small, frequent feedings. Explanation: An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy, and vomiting, which are associated with increased intracranial pressure. Small, frequent feedings given at times when the infant is relaxed and calm are tolerated best. Feeding an infant before any procedure is inappropriate because the stress of the procedure may lead to vomiting. Ideally, the infant should be held in a slightly vertical position when feeding to prevent backflow of formula into the eustachian tubes and subsequent development of ear infections. Giving large, less frequently feedings allows for rest, but typically results in more vomiting. Remediation: Ventriculoperitoneal shunt placement Hydrocephalus, pediartic Question 8 See full question A 13-year-old child has seen the school nurse several times with headache, vomiting, and difficulty walking. When calling the adolescent's mother about these symptoms, what should the nurse suggest the mother do first? You Selected: Make an appointment with the adolescent's health care provider (HCP). Correct response: Make an appointment with the adolescent's health care provider (HCP). Explanation: A child who has symptoms of vomiting, headaches, and problems walking needs to be evaluated by a health care provider (HCP) to determine the cause. Unexplained headaches and vomiting along with difficulty walking (e.g., ataxia) may suggest a brain tumor. Evaluation by an eye HCP would be appropriate once a complete medical evaluation has been accomplished. Psychological counseling may be indicated for this adolescent, but only after medical evaluation to determine that she is physically healthy. Meeting with the child’s teachers would be appropriate after medical evaluation. Remediation: Physical assessment, pediatric Question 9 See full question A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client: You Selected: tea and gelatin dessert. Correct response: tea and gelatin dessert. Explanation: A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet. Remediation: Vomiting Question 10 See full question Clozapine therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, "Why do I have to have a blood test every week?" Which response by the nurse would be most appropriate? You Selected: "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood." Correct response: "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood." Explanation: The client needs specific information about the effects of the drug, specifically that the drug can cause agranulocytosis. The statement about weekly blood tests to determine safe dosage and monitoring for effects on the blood gives the client specific information to ensure follow-up with the required protocol for clozapine therapy. Lack of accurate knowledge can lead to noncompliance with necessary follow-up procedures and noncompliance with medication. The supply of medication is not dependent on blood testing. Telling the client that the health care provider (HCP) wants to know the progress does not provide specific information for this client. The blood tests are not required by the drug company. Remediation: Clozapine Question 11 See full question A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers him to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation?