the nurse prepares to administer digoxin lanoxin to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 2

1. The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?

Correct answer: B

Rationale: An apical rate of 140 bpm is within the normal range for a newborn. Digoxin is commonly used to treat heart failure by increasing the strength and efficiency of the heart's contractions. Since the heart rate is within the normal range, there is no need to hold the medication or notify the healthcare provider. Rechecking the apical rate in an hour is unnecessary as the heart rate is not alarming. Therefore, the appropriate nursing action is to administer the digoxin.

2. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip prior to initiating Coumadin could leave the patient without anticoagulation coverage during the period when warfarin's effects are not yet established. Checking the client's INR prior to beginning Coumadin is important but not the immediate action to take when both medications are ordered together. Clarifying the order with the health care provider is unnecessary in this scenario as it is common practice to give heparin and warfarin concurrently in the transition period.

3. The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?

Correct answer: A

Rationale: The correct anatomical position for auscultating the murmur of aortic stenosis is the second intercostal space, right sternal border. This is where the aortic valve is best auscultated, and the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as the murmur of aortic stenosis is best heard at the second intercostal space on the right side of the sternum.

4. The HCP orders cultures of the urethral urine, bladder urine, and prostatic fluid. Which instructions would the nurse teach to achieve the first two (2) specimens?

Correct answer: A

Rationale: To obtain accurate cultures of urethral and bladder urine, the nurse should instruct the patient to collect the first 15 mL of urine in one container and the subsequent 50 mL in another. This method ensures that the specimens are separated appropriately for analysis. Choices B, C, and D are incorrect because collecting three early morning urine specimens, massaging the prostate, or collecting a routine urine specimen would not provide the specific separation of urethral and bladder urine required for this particular test.

5. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?

Correct answer: A

Rationale: The correct answer is A. Removing sequential compression devices could increase the risk of thromboembolism, which is a serious complication. Therefore, this client should be seen first to prevent any potential harm. Choice B may be important, but it does not pose an immediate risk compared to thromboembolism. Choice C is a routine care task that can be delayed, and Choice D, discontinuing intravenous fluid, is important but not as urgent as preventing thromboembolism.

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