a nurse is preparing to administer a dose of warfarin which of the following actions should the nurse take
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN

1. A healthcare professional is preparing to administer a dose of warfarin. Which of the following actions should the healthcare professional take?

Correct answer: A

Rationale: Corrected Rationale: When administering warfarin, it is crucial to verify the patient's INR levels. INR monitoring is essential to ensure that the patient is receiving the correct dose of warfarin for their condition and to minimize the risk of bleeding. Choices B, C, and D are incorrect because administering warfarin with food, monitoring blood glucose levels, and assessing liver function are not directly related to the safe administration and monitoring of warfarin therapy.

2. A nurse is teaching a newly licensed nurse about contraindications to ceftriaxone. The nurse should include a severe allergy to which of the following medications as a contraindication to ceftriaxone?

Correct answer: C

Rationale: Ceftriaxone is a cephalosporin, and individuals with a penicillin allergy (such as Piperacillin) may have cross-sensitivity, making it contraindicated. Gentamicin (Choice A) belongs to the aminoglycoside class, not related to cephalosporins. Clindamycin (Choice B) is a lincosamide antibiotic and is not typically associated with cross-allergies to cephalosporins. Sulfamethoxazole-trimethoprim (Choice D) is a sulfonamide antibiotic, also not directly related to ceftriaxone.

3. A nurse is in an acute care facility, caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?

Correct answer: B

Rationale: The correct answer is B: 'Suppression of the urge to defecate.' Suppressing the urge to defecate can lead to constipation, especially in postoperative clients. It is essential to encourage clients to respond to the urge to defecate to prevent constipation. Increased fiber intake (Choice A) is beneficial for preventing constipation. Ambulation (Choice C) helps promote bowel motility and can reduce the risk of constipation. Daily laxative use (Choice D) may contribute to laxative dependence but is not the behavior most directly associated with increasing the risk of constipation in this scenario.

4. A nurse is caring for a client receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?

Correct answer: A

Rationale: Corrected Rationale: If infiltration is suspected, the nurse should immediately stop the dopamine infusion to prevent further damage to the surrounding tissue. Choice A is the correct answer because continuing the infusion can lead to tissue damage and compromise the client's care. Slowing the infusion (Choice B) is not sufficient to prevent harm and may still cause damage. Applying a warm compress (Choice C) or a cold compress (Choice D) is not the recommended action for infiltration; stopping the infusion is crucial to prevent complications.

5. A healthcare provider is assessing a client who is receiving IV gentamicin three times daily. Which of the following findings indicates that the client is experiencing an adverse effect of this medication?

Correct answer: B

Rationale: Corrected Rationale: Gentamicin is known to cause nephrotoxicity as an adverse effect. Proteinuria, which is the presence of excess proteins in the urine, may indicate kidney damage from the medication. Monitoring renal function is crucial in clients receiving gentamicin. Choice A, hypoglycemia, is not a typical adverse effect of gentamicin. Choices C and D, nasal congestion and visual disturbances, are not commonly associated with gentamicin use or its adverse effects.

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