ATI RN Pharmacology 2023 -Nurselytic

Correct Answer: D

Rationale: The correct answer is D: Apply the tourniquet 5 to 10 cm (about 2 to 4 in) above the IV insertion site. This step is crucial in initiating IV therapy as it helps to visualize and access the veins more easily. By applying the tourniquet at the correct distance from the insertion site, the nurse can create venous congestion, making the veins more prominent and easier to puncture. This step also helps to slow down the blood flow, making it easier to insert the IV catheter. It is important to apply the tourniquet properly to avoid causing discomfort or compromising blood flow to the extremity.

Incorrect choices:
A: Insert the IV catheter using the Z-track technique - The Z-track technique is used for intramuscular injections, not IV therapy.
B: Insert the IV catheter with the bevel down - The bevel of the IV catheter should be facing up for proper insertion into the vein.
C:

Correct Answer: C

Rationale:
Correct Answer: C - Ensure the client has advance directives on file.


Rationale: Advance directives allow the client to specify their wishes regarding medical treatment if they become unable to communicate. In the case of a client with stage 4 cancer scheduled for surgery, having advance directives in place ensures their wishes are respected, including preferences for end-of-life care. This action promotes autonomy and patient-centered care.

Summary of Other

Choices:
A: Incorrect. The client has the right to refuse surgery even after signing a consent form. Coercion is unethical.
B: Incorrect. While it is important to explain risks, ensuring advance directives is a higher priority in this scenario.
D: Incorrect. This question pertains to surgery, not resuscitation preferences. Advance directives are more relevant in this context.

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: 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.

Correct Answer: D,E

Rationale: Parameters:

Correct Answer: (0, 0, 0, 1, 1, 0, 0)


Rationale:
- Atelectasis is a condition where the lungs do not expand fully, increasing the risk of respiratory complications.
- Paralytic ileus is a condition where the intestines stop working, leading to potential bowel obstruction.
- Urinary tract infection, delayed wound healing, and deep vein thrombosis are not directly related to the client's risk factors in this scenario.