a nurse is caring for a client who is receiving tpn which of the following actions should the nurse take to prevent infection
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?

Correct answer: D

Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.

2. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: The correct answer is B: Pallor. Pallor, which is paleness of the skin, is a common sign of anemia due to a decreased number of red blood cells or hemoglobin levels. This results in reduced oxygen-carrying capacity, leading to the paleness of the skin. Choice A, increased appetite, is not typically associated with anemia. Choice C, tachycardia (increased heart rate), can be present in anemia as the body compensates for decreased oxygenation. Choice D, hypertension (high blood pressure), is not a common finding in anemia; instead, low blood pressure may be observed due to decreased blood volume.

3. How should a healthcare provider monitor a patient who has been prescribed digoxin?

Correct answer: C

Rationale: The correct way to monitor a patient who has been prescribed digoxin is by checking digoxin levels. Digoxin is a medication used to treat various heart conditions, and monitoring its levels in the blood is crucial to prevent toxicity. Monitoring potassium levels (Choice A) is important as well, as digoxin can affect potassium levels, but checking digoxin levels is more specific to monitoring the medication itself. Monitoring heart rate (Choice B) is relevant but does not directly assess the medication levels. Checking blood glucose levels (Choice D) is not typically indicated specifically for patients prescribed digoxin.

4. A client with schizophrenia is pacing the hall and is agitated. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia who is pacing the hall and agitated is to walk with the client at a gradually slower pace. This approach can help reduce the client's agitation and prevent the situation from escalating. Choice A is incorrect because directly asking about harm may increase the client's anxiety. Choice B is inappropriate as it may worsen the client's agitation. Choice C is not recommended as the client may benefit from the nurse's presence and support during this time of distress.

5. A client with asthma is prescribed a corticosteroid inhaler. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction is to rinse the mouth after each use of a corticosteroid inhaler to prevent oral candidiasis (thrush). Choice A is incorrect because corticosteroid inhalers are usually used on a regular schedule to control asthma symptoms, not just for acute symptoms. Choice C is incorrect as corticosteroid inhalers are typically used for long-term management, not just during asthma attacks. Choice D is incorrect as administering a bronchodilator after using a corticosteroid is not a standard practice and is not necessary for the effectiveness of the corticosteroid inhaler.

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