a nurse is preparing to administer eye drops to a school age child identify the actions the nurse should take move the steps into the box on the right

ATI RN

ATI Fundamentals Proctored Exam

1. When preparing to administer eye drops to a school-age child, what actions should a nurse take?

A. 52341
B. 53241
C. 35241
D. 14325

Correct answer: A

Rationale: The correct sequence for administering eye drops to a school-age child is as follows: 5. Place the child in a sitting position, 2. Ask the child to look upward, 3. Pull the lower eyelid downward, 4. Instill the drops of medication, and 1. Apply pressure to the lacrimal punctum. Placing the child in a sitting position helps with stability and ease of access. Asking the child to look upward helps expose the conjunctival sac. Pulling the lower eyelid downward creates a pouch for instilling the drops. Instilling the drops of medication directly into the pouch ensures proper administration, and applying pressure to the lacrimal punctum prevents systemic absorption and promotes local action of the medication.

2. Palpating the midclavicular line is the correct technique for assessing

A. Baseline vital signs
B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse

Correct answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.

3. During a Romberg test, the patient is asked to assume which position?

A. Sitting
B. Standing
C. Genupectoral
D. Trendelenburg

Correct answer: B

Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.

4. During the removal of a chest tube, what should the nurse instruct the client to do?

A. Lie on their left side.
B. Use the incentive spirometer.
C. Cough at regular intervals.
D. Perform the Valsalva maneuver.

Correct answer: D

Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.

5. A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?

A. ''I am allergic to morphine.''
B. ''I take antacids several times a day.''
C. ''I had a blood clot in my leg several years ago.''
D. ''It hurts to take a deep breath.''

Correct answer: B

Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.