ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
A patient who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive which antidote?
Correct Answer: B
Rationale: The correct antidote for a patient who has taken too much warfarin is Vitamin K. Warfarin inhibits Vitamin K-dependent clotting factors, leading to bleeding. Vitamin K helps restore these clotting factors. Vitamin E does not reverse warfarin's effects. Protamine sulfate is an antidote for heparin, not warfarin. Potassium chloride is used for treating low potassium levels, not warfarin toxicity. In summary, Vitamin K is the correct antidote for warfarin toxicity due to its role in restoring Vitamin K-dependent clotting factors, while the other choices are not indicated for this specific situation.
Question 2 of 5
An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram?(Select the one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A. Hypertension alone may not directly warrant an electrocardiogram (ECG) as it primarily indicates high blood pressure. However, fatigue despite adequate rest, indigestion, and abdominal pain can be symptoms of underlying cardiac issues that require an ECG for further evaluation. Fatigue can be a sign of heart problems affecting oxygen delivery, while indigestion and abdominal pain can be symptoms of a heart attack or other cardiac conditions. Requesting an ECG based on these symptoms can help identify potential cardiac issues early on.
Question 3 of 5
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that do not apply.)
Correct Answer: A
Rationale: Step-by-step rationale: 1. Chest x-ray is not routinely scheduled annually for monitoring complications in type 2 diabetes. 2. Blood pressure monitoring is essential for assessing cardiovascular risk in diabetic patients. 3. Serum creatinine levels are checked annually to assess kidney function. 4. Urine for microalbuminuria is done annually to detect early signs of kidney damage. 5. Since chest x-ray is not directly related to diabetes complications, it is the correct answer. Summary: A is correct because chest x-ray is not a standard test for monitoring type 2 diabetes complications. B, C, and D are incorrect as they are essential for evaluating cardiovascular risk, kidney function, and early signs of kidney damage in diabetic patients.
Question 4 of 5
Which action should the nurse plan to prevent aspiration in a high-risk patient?
Correct Answer: B
Rationale: The correct answer is B: Place a patient with altered consciousness in a side-lying position. This position helps prevent aspiration by reducing the risk of regurgitated material entering the airway. Patients with altered consciousness are at higher risk of aspiration due to impaired protective airway reflexes. Placing them in a side-lying position helps maintain an open airway and facilitates drainage of secretions. Incorrect choices: A: Turning and repositioning an immobile patient every 2 hours is important for preventing pressure ulcers, not aspiration. C: Inserting a nasogastric tube for feeding does not directly prevent aspiration; it is a method of providing nutrition. D: Monitoring respiratory symptoms in an immunosuppressed patient is important for detecting infections but does not directly prevent aspiration.
Question 5 of 5
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Perform a test focused on a neurologic examination. The client's symptoms indicate potential neurological issues, such as vision difficulties and constant nasal drainage, which could be related to nerve damage from the nasal fracture. By performing a neurologic examination, the nurse can assess for any nerve involvement and determine the extent of the injury. This action is crucial in identifying any neurological complications and guiding appropriate treatment. Summary: A: Collecting nasal drainage does not address the client's neurological symptoms. B: Encouraging the client to blow his or her nose could exacerbate the nasal fracture and is not relevant to the neurological symptoms. D: Palpating the nose, face, and neck may help assess the extent of the fracture but does not address the neurological symptoms reported by the client.