the nurse is preparing to assist in examining a hispanic child who was brought to the clinic by the mother during the assessment of the child the nurs
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 4

1. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

Correct answer: C

Rationale: Building rapport with the child is essential to establish trust and cooperation during the assessment. Admiring the child may not be appropriate in a professional setting and might not contribute significantly to the assessment. Taking the child's temperature is a routine part of the assessment but may not be the most critical action in this scenario. Obtaining an interpreter is crucial to ensure effective communication between the healthcare team and the child and their mother, especially considering potential language barriers.

2. Which of the following is a potential side effect associated with the use of nonsteroidal anti-inflammatory drugs?

Correct answer: A

Rationale: The correct answer is A: Stomach irritation and bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause stomach irritation and bleeding due to their effects on gastric mucosa. Stomatitis and esophagitis (Choice B) are not typically associated with NSAID use. While NSAIDs may affect renal function, leading to fluid retention and edema, they do not directly cause increased potassium excretion (Choice D). Impaired folate absorption (Choice C) is not a common side effect of NSAIDs.

3. A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?

Correct answer: D

Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member, with the consent being witnessed by two healthcare providers, is the best course of action. This ensures that the client's best interests are considered and that proper authorization is obtained. Option A, obtaining a court order, is not necessary in this scenario and could delay the surgery. Option B, signing the consent on behalf of the client, is not appropriate as it may raise ethical and legal concerns. Option C, sending the client to surgery without a signed consent form, is not advisable as it violates the principles of informed consent and places the client at risk.

4. What intervention should the nurse implement for the client who has an ileal conduit?

Correct answer: C

Rationale: The correct intervention for a client with an ileal conduit is to report any decrease in urinary output to the healthcare provider. Decreased urinary output in these clients may indicate a blockage or another complication, which requires immediate attention. Monitoring the stoma for signs of infection (Choice D) is important but not the priority when compared to a decrease in urinary output. Pouching the stoma with a one-inch margin around it (Choice A) is incorrect as it does not address the issue of decreased urinary output. Referring the client to the United Ostomy Association (Choice B) is not necessary in this immediate situation where a potential complication is suspected.

5. In which situation(s) does the nurse act as a client advocate?

Correct answer: D

Rationale: The correct answer is D because all the situations listed reflect aspects of client advocacy. Pulling the curtain around the client's bed while changing a dressing ensures privacy and dignity for the client, which is an essential part of advocacy. Contacting the health care provider to request a meeting for the client involves advocating for the client's needs and preferences. Ensuring access to medical information by appropriate personnel only is another way the nurse advocates for the client by safeguarding their confidentiality and promoting proper communication. Choices A, B, and C all demonstrate different aspects of advocacy, making option D the correct choice.

Similar Questions

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