ATI COMPREHENSIVE EXIT EXAM – PRIORITY ONE 100% Verified Q&A

ATI COMPREHENSIVE EXIT EXAM – PRIORITY ONE 1. A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor. Which of the following nursing actions should the nurse take? p. 88 Ch. 13 maternity a. Continue the monitor the fetal heart rate- - Not a problem- absent or late are a problem however CONFIRMED b. Stop the oxytocin infusion c. Perform a vaginal examination d. Initiate an amnioinfusion 2. A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Complete an incident report and place it in the client's medical record. b. Compare the current infusion with the prescription in the client's medication record c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident. 3. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ? a. WBC count 2,900 /mm3 - AGRANULOCYTOSIS - 4,800- 15,000 is normal range b. FAsting blood glucose 100 mg/dl c. Hgb 14 g/Dl d. Heart rate 58/min ATI PHARM 116 Complications 4. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. You may breastfeed unless your nipples are cracked or bleeding. b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. Rationale: CDC states that: There is no documented evidence that breastfeeding spreads HCV. Therefore, having HCV-infection is not a contraindication to breastfeed. HCV is transmitted by infected blood, not by human breast milk. There are no current data to suggest that HCV is transmitted by human breast milk. However, HCV is spread by infected blood. Therefore, if the HCV-positive mother’s nipples and/or surrounding areola are cracked and bleeding, she should stop nursing temporarily. Instead, she should consider expressing and discarding her breast milk until her nipples are healed. Once her breasts are no longer cracked or bleeding, the HCV-positive mother may fully resume breastfeeding. 5. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? Exhibit. a. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain b. Skin turgor c. Deep-tendon reflexes d. Bowel sounds 6. A nurse is caring for a client who has hyperthermia