ATI RN Pharmacology 2023 -Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Measure the client's respiratory rate. This is the first action the nurse should take because an overdose of morphine can lead to respiratory depression, which is a life-threatening complication. By assessing the client's respiratory rate, the nurse can quickly determine if the client is experiencing any respiratory distress and needs immediate intervention. Reporting the incident to the pharmacy (
A) or completing an incident report (
D) can be done after ensuring the client's safety. Notifying the client's provider (
B) can be important but assessing the respiratory rate takes precedence in this situation.

Correct Answer: C

Rationale: The correct answer is C: Decreased bladder tone can cause urinary retention. In older adults, decreased bladder tone can lead to incomplete emptying of the bladder, increasing the risk of urinary tract infection. Bladder capacity decreasing (
A) is a normal part of aging but does not directly increase the risk of UTI. The urethral sphincter functioning less efficiently (
B) may contribute to urinary incontinence but not directly to UTI. The ability to concentrate urine decreasing (
D) is a normal part of aging but does not directly impact UTI risk.

Correct Answer: C

Rationale:
Correct Answer: C - Cleanses the meatus from the center in a circular motion.


Rationale:
1. Cleansing the meatus from the center in a circular motion helps to prevent contamination by moving from the least contaminated area to the most contaminated area.
2. This technique minimizes the risk of introducing microorganisms into the urethra during the catheterization procedure.
3. By starting from the center and moving outward, the nurse ensures thorough cleaning of the meatus and reduces the chance of introducing infection.

Incorrect

Choices:
A: Grasping the catheter 10.16 to 12.7 cm (4 to 5 in) from the tip - Incorrect because holding the catheter too close to the tip can lead to contamination.
B: Cleansing the meatus using a clean cotton ball - Incorrect because a cotton ball may leave fibers behind, increasing the risk of infection.
D: Applying clean gloves before beginning the procedure - Incorrect because clean gloves are necessary but do not

Correct Answer: B

Rationale:
Correct Answer: B


Rationale:
The correct answer is B because sharing health information with a relative without the client's permission would violate client confidentiality. Respecting a client's right to privacy and obtaining their consent before sharing sensitive information is crucial in maintaining confidentiality. This principle is in line with ethical standards and legal requirements, such as the Health Insurance Portability and Accountability Act (HIPA
A). It demonstrates a clear understanding of the importance of protecting client privacy.

Incorrect choices:
A: Sharing client information in public areas like hallways violates confidentiality.
C: Sharing a client's diagnosis with any health care team member may not be necessary for their care and could breach confidentiality.
D: While accessing medical records may require permission, written permission from the provider is not specifically needed for a client to access their own records.

Correct Answer: A

Rationale: The correct answer is A: High-pitched wheezing. This finding indicates a potential severe allergic reaction, such as anaphylaxis, which requires immediate medical attention. Wheezing can be a sign of airway constriction and respiratory distress, which could lead to serious complications if not treated promptly. Urticaria (choice
B) and pruritis (choice
C) are common side effects of amoxicillin and can often be managed with antihistamines. Rhinitis with clear discharge (choice
D) is not typically a sign of a severe allergic reaction. Reporting high-pitched wheezing ensures timely intervention to prevent respiratory compromise.