a nurse is assessing a client who is receiving morphine via a patient controlled analgesia pca pump which of the following findings should the nurse r
Logo

Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D because a blood pressure drop or other signs of morphine overdose should be reported, especially when using a PCA pump. Choices A, B, and C are within normal limits and do not indicate an immediate concern related to morphine administration.

2. A nurse is reviewing the medical records of a client with a history of depression who is experiencing a situational crisis. What should the nurse do first?

Correct answer: A

Rationale: Confirming the client's perception of the event is crucial in understanding how they are interpreting the crisis situation. This helps the nurse gain insight into the client's perspective, emotions, and needs. By validating the client's perception, the nurse can establish trust and rapport, which are essential in providing effective support during a crisis. Notifying the client's support system (Choice B) may be important but should come after understanding the client's perspective. Helping the client identify personal strengths (Choice C) and teaching relaxation techniques (Choice D) are valuable interventions but should follow the initial step of confirming the client's perception to ensure individualized care.

3. When using an IV pump for a newly admitted client, what action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when using an IV pump for a newly admitted client is to hold the IV pump cord while walking the client. This is important for ensuring the safe and secure management of the IV pump during client mobility. Option A is incorrect as grasping the IV pump cord when unplugging it can lead to electrical hazards. Option B is incorrect as ensuring the pump is plugged into an outlet with two prongs is important for electrical safety but not directly related to the nurse's action. Option D is also important but does not directly address the nurse's immediate action while using the IV pump with the client.

4. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction the nurse should include is to advise the client to avoid consuming foods high in vitamin K. Foods rich in vitamin K, such as leafy greens, can interfere with the effectiveness of warfarin, an anticoagulant medication. Therefore, it is important for clients on warfarin therapy to maintain consistent vitamin K intake to keep their INR levels stable. The other options are also important but not the priority in the context of warfarin therapy. Ingesting foods high in vitamin K can affect the medication's efficacy, making it crucial to highlight this dietary consideration during client education.

5. A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Taking the pulse before taking digoxin is crucial as it helps monitor the heart rate, as digoxin can cause bradycardia as a side effect. Option B is incorrect because digoxin should be taken on an empty stomach to enhance absorption. Option C is incorrect because digoxin should be held and the healthcare provider should be contacted if the heart rate is less than 60/min. Option D is incorrect because digoxin should not be taken with food due to decreased absorption.

Similar Questions

A nurse in a pediatric clinic is reviewing laboratory findings for a school-age child. Which of the following findings should the nurse report to the provider?
What is the appropriate nursing action for a patient experiencing an acute allergic reaction?
A nurse is planning care for a client who is receiving hemodialysis. Which action should the nurse include in the care plan?
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?
A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses