a guideline that is utilized in determining priorities is to assess the status of the following except

ATI RN

Nutrition ATI Test

1. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:

A. perfusion
B. locomotion
C. respiration
D. mentation

Correct answer: D

Rationale: When determining priorities in patient care, assessing perfusion, respiration, and locomotion are crucial. However, assessing mentation is also important but not typically included in the ABCs of emergency care. Monitoring mentation is essential for neurological assessment and detecting changes in mental status, but it is not part of the immediate priorities in life-threatening situations.

2. During blood administration, what is essential for the nurse to do in order to carefully monitor for adverse reactions?

A. Stay with the client for the first 15 minutes of blood administration
B. Stay with the client for the entire period of blood administration
C. Run the infusion at a faster rate during the first 15 minutes
D. Inform the client to notify the staff immediately for any adverse reaction

Correct answer: A

Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.

3. What is the most important concern immediately after a myocardial infarction?

A. Reducing cholesterol intake
B. Allowing cardiac rest for healing
C. Reducing saturated fat intake
D. Eating several small meals each day

Correct answer: B

Rationale: Immediately after a myocardial infarction, the primary concern is to allow the heart to rest and heal to prevent further damage. This is why choice B is the correct answer. While choices A, C, and D might be a part of the long-term management plan following a myocardial infarction, they are not the immediate priority. Reducing cholesterol and saturated fat intake, as well as adjusting eating habits can help prevent future heart issues, but do not directly contribute to the immediate recovery post-myocardial infarction.

4. All of the following are electrolytes except:

A. chloride
B. potassium
C. sodium
D. iron

Correct answer: D

Rationale: Iron is not an electrolyte; electrolytes like sodium, potassium, and chloride help maintain fluid balance and are critical for nerve and muscle function.

5. Which is the best description of a full-liquid diet?

A. Most suitable for individuals with an ileostomy
B. Suitable for individuals with lactose intolerance
C. Contains low saturated fat and high fiber
D. Provides adequate nutrients and is easily digested

Correct answer: D

Rationale: The correct answer is D because a full-liquid diet is designed to provide adequate nutrients while being easily digested. Choices A and B are incorrect because a full-liquid diet is not specifically tailored for individuals with an ileostomy or lactose intolerance. Choice C is also incorrect as it describes characteristics that are not defining features of a full-liquid diet.