ATI RN MED SURG PROCTORED EXAM WITH COMPLETE SOLUTION |RATED A+

ATI RN MED SURG PROCTORED EXAM WITH COMPLETE SOLUTION |RATED A+ A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client repor ...

ATI RN MED SURG PROCTORED EXAM WITH COMPLETE SOLUTION |RATED A+ A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? Stop the medication infusion. Notify the charge nurse. Administer a PRN dose of diphenhydramine. Follow facility policy for appropriate reporting of the adverse reaction. RATIONALE: The greatest risk to the client is injury from an allergic response to the medication. Therefore, the first action the nurse should take is to stop the medication infusion. A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? Pruritus Nausea Urinary retention Dyspnea RATIONALE: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is dyspnea, which is a complication of the epidural infusion. A nurse is assisting in the plan of care regarding bowel training for a client who has cervical spinal cord injury. Which of the following interventions should the nurse implement first? Determine the client's daily elimination habits. Administer a suppository to the client 30 min prior to defecation time. Offer the client 4 oz of warm prune juice to promote elimination. Provide dietary bulk to the client to ease the passage of stool. RATIONALE: The first action the nurse should take when using the nursing process is to collect data on the client's daily bowel elimination habits to establish a routine defecation time. A nurse is reinforcing teaching with a client who has systemic lupus erythematous (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? "Take the medication on an empty stomach." "Limit contact with large groups of people." "Avoid taking over-the-counter calcium supplements." "Follow a low-protein diet." RATIONALE: Glucocorticoids cause immunosuppression and can mask infection. The client should limit contact with sources of possible infections, such as large groups of people. A nurse is contributing to the plan of care for a client who has MRSA infection and is on contact isolation precautions. Which of the following actions should the nurse take? Keep the door of the client's room closed at all times. Remove gloves after leaving the client's room. Wear a mask when working within 1 m (3 feet) of the client. Have a designated stethoscope in the client's room. RATIONALE: The nurse should designate equipment to leave in the client's room to avoid cross-contamination. The designated equipment should be disposed of or decontaminated before leaving the client's room. A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? Gown Mask Sterile gloves Protective eyewear RATIONALE: The nurse should identify that a client who has meningococcal pneumonia requires droplet precautions, which include wearing a mask when providing care within 1 m (3 feet) of the client. A nurse enters the room of a client whose transfusion of packed RBCs initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After the stopping the infusion, which of the following actions should the nurse take? Collect a urine sample. Take the client's vital signs. Return the blood to the laboratory. Administer an antihistamine. A nurse is contributing to the plan of care for a client who has partial hearing loss. Which of the following interventions should the nurse include in the plan of care? Face the client while speaking. Use a high-pitched tone when talking to the client. Avoid using gestures when communicating. Repeat misunderstood phrases. RATIONALE: The nurse should face the client, which allows the client to see who is speaking, read the nurse's lips, and obtain visual cues by observing facial expressions.