Review ATI NURS125 Maternal Newborn exam

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ATI NURS125 Maternal Newborn exam

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Total Questions : 29

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Question 1:

A nurse is administering a powdered medication to a client.
Which of the following actions should the nurse take first?

A. Document that the medication was administered. B. Mix the medication at the client's bedside. C. Check the client for allergies. D. Determine the client's response to the medication.

Answer and Explanation

Choice A:

Documenting the medication administration is important but should be done after administering the medication. Documentation ensures proper tracking and accountability but does not address immediate patient safety concerns like checking for allergies.

Choice B:

Mixing the medication at the client's bedside may ensure that the medication is prepared correctly and the client receives it promptly, but it doesn't address the critical step of ensuring the client's safety by checking for allergies first.

Choice C:

Checking the client for allergies is crucial before administering any medication, including powdered forms. Allergic reactions can be severe or life-threatening, so it’s essential to ensure that the client isn’t allergic to the medication. This step ensures the safety and well-being of the client and prevents potential adverse reactions.

Choice D:

Determining the client's response to the medication is important for assessing the medication's effectiveness and identifying any adverse reactions, but it occurs after administration. Checking for allergies precedes all these steps to prevent any initial harm.

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Question 2:

A nurse is planning care for a client who requires screening for rectal cancer.
Which of the following tests should the nurse anticipate in the client's care?

A. Colonoscopy. B. Endoscopic retrograde cholangiopancreatography (ERCP). C. Upper GI series. D. Upper GI endoscopy.

Answer and Explanation

Choice A:

Colonoscopy is the recommended test for screening for rectal cancer. It allows for direct visualization of the entire colon and rectum, enabling the detection and biopsy of polyps or suspicious lesions. It is the gold standard for colorectal cancer screening.

Choice B:

Endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat conditions of the bile ducts, pancreas, and gallbladder. It’s not typically used for colorectal cancer screening.

Choice C:

An upper GI series involves X-rays of the upper gastrointestinal tract (esophagus, stomach, and duodenum) after swallowing a contrast medium. This test does not visualize the lower GI tract, including the colon and rectum, and is therefore not suitable for rectal cancer screening.

Choice D:

Upper GI endoscopy allows for direct visualization of the upper gastrointestinal tract but does not reach the colon and rectum. Hence, it is not used for screening rectal cancer.

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Question 3:

A nurse is preparing to administer an enema to a client.
Which of the following actions should the nurse plan to take?

A. Place the client into a right lateral position. B. Warm the enema solution to room temperature. C. Use sterile technique. D. Lubricate the tubing with an oil-based lubricant.

Answer and Explanation

Choice A:

Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the solution into the colon.

Choice B:

Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping, making the procedure less tolerable for the client.

Choice C:

Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.

Choice D:

Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the absorption of the enema solution. Water-soluble lubricants are preferred.

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Question 4:

A nurse is teaching a class about routes of medication administration.
The nurse should include that which of the following routes has the fastest rate of absorption?

A. Enteral. B. Intramuscular. C. Topical. D. Intravenous.

Answer and Explanation

Choice A:

Enteral administration involves the gastrointestinal tract, including oral and feeding tube methods. Absorption is slower as the medication passes through the digestive system before entering the bloodstream.

Choice B:

Intramuscular (IM) administration involves injecting the medication into muscle tissue, where it is absorbed into the bloodstream. Absorption is quicker than enteral routes but slower compared to IV administration.

Choice C:

Topical administration involves applying medication to the skin or mucous membranes. Absorption is generally slower and is intended for local or systemic effects, depending on the medication.

Choice D:

Intravenous (IV) administration has the fastest rate of absorption because the medication is delivered directly into the bloodstream, bypassing the absorption barriers of the digestive system or muscle tissue. This ensures rapid onset of action.

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Question 5:

A nurse is teaching a newly licensed nurse about the function of the large intestine.
Which of the following information should the nurse include?

A. It produces vitamin D. B. It prevents the reflux of food into the esophagus. C. It absorbs liquid to form stool. D. It secretes enzymes to digest food.

Answer and Explanation

Choice A:

The large intestine does not produce vitamin D; this occurs in the skin when exposed to sunlight. The large intestine’s primary functions are absorption and waste formation.

Choice B:

Preventing the reflux of food into the esophagus is the function of the lower esophageal sphincter, not the large intestine. The large intestine deals with waste processing rather than regulating esophageal function.

Choice C:

The large intestine absorbs water and electrolytes from the remaining indigestible food matter, forming and eliminating solid waste (stool). This absorption process is vital for maintaining the body's fluid and electrolyte balance.

Choice D:

The secretion of digestive enzymes is a function of the pancreas, stomach, and small intestine. The large intestine does not secrete enzymes but focuses on absorbing water and electrolytes.

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Question 6:

A nurse is assessing a client who has dehydration.
Which of the following findings should the nurse expect?

A. Cloudy urine. B. Urine osmolality of 200 mOsm/kg. C. Urine specific gravity of 1.015. D. Dark-colored urine.

Answer and Explanation

Choice A:

Cloudy urine is not typically associated with dehydration. It may indicate the presence of an infection, inflammation, or other medical conditions.

Choice B:

Urine osmolality of 200 mOsm/kg suggests diluted urine, which is contrary to the expectation in dehydration. Dehydration would typically result in higher urine osmolality as the kidneys conserve water.

Choice C:

Urine specific gravity of 1.015 falls within the normal range (1.005 to 1.030). In dehydration, specific gravity would be expected to be higher as the urine becomes more concentrated to conserve water. .

Choice D:

Dark-colored urine is a common indicator of dehydration. When the body is dehydrated, urine becomes more concentrated, leading to darker color due to higher levels of waste products.

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Question 7:

A nurse opens a unit-dose of a prescribed medication prior to administering it to a client.
The client refuses to take the medication.
Which of the following actions should the nurse take?

A. Return the opened medication to the medication cart. B. Report the incident to the provider. C. Fill out an incident report. D. Notify the facility's ethics committee.

Answer and Explanation

Choice A:

Returning the opened medication to the medication cart is inappropriate because once a medication is opened and refused by a client, it must be disposed of properly. This action helps maintain safety and prevents contamination.

Choice B:

Reporting the incident to the provider is not necessary in this context as the refusal to take medication can be managed by the nurse by following the facility's protocol.

Choice C:

Filling out an incident report is required because the client's refusal to take the medication is considered a significant event. Incident reports are used to document and analyze such events to improve patient care and safety.

Choice D:

Notifying the facility's ethics committee is unnecessary for a medication refusal incident, as it does not involve an ethical dilemma requiring their intervention.

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Question 8:

A nurse is teaching a newly licensed nurse about adverse effects of medications.
The nurse should include that which of the following medications can cause constipation?

A. Anticholinergics/antispasmodics. B. Opioid narcotics. C. Iron supplements. D. Magnesium-containing antacids.

Answer and Explanation

Choice A:

Anticholinergics/antispasmodics can cause constipation by reducing the muscle contractions of the gastrointestinal tract, leading to slower movement of contents and resulting in constipation.

Choice B:

Opioid narcotics cause constipation by binding to opioid receptors in the gastrointestinal tract, which decreases intestinal motility and inhibits the secretion of fluids, leading to hard and dry stools.

Choice C:

Iron supplements can cause constipation as a common side effect due to their effect on the gastrointestinal tract. They can make stools harder and more difficult to pass.

Choice D:

Magnesium-containing antacids typically do not cause constipation. In fact, they are more likely to have a laxative effect due to the presence of magnesium, which can increase water in the intestines and soften stools.

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Question 9:

A nurse is assessing a client who has had diarrhea for several days.
Which of the following findings should the nurse expect?

A. Hypothermia. B. Rigid abdomen. C. Decreased bowel sounds. D. Dehydration.

Answer and Explanation

Choice A:

Hypothermia is not commonly associated with diarrhea. Diarrhea typically leads to fluid loss and dehydration rather than changes in body temperature.

Choice B:

A rigid abdomen is not a typical finding for diarrhea. It may indicate other gastrointestinal issues, such as peritonitis, rather than dehydration caused by diarrhea.

Choice C:

Decreased bowel sounds are not typically expected with diarrhea, which often presents with increased bowel sounds due to increased motility.

Choice D:

Dehydration is a common finding in clients with diarrhea due to the excessive loss of fluids and electrolytes from frequent, loose stools. It can lead to symptoms such as dry mouth, reduced urine output, and dizziness.

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Question 10:

A nurse is teaching a newly licensed nurse about obtaining a fecal occult blood test from a client.
Which of the following information should the nurse include?

A. Collect two stool specimens from the same area of the stool. B. Use toilet paper to transfer the stool specimen. C. Apply four drops of developing solution to each stool specimen. D. Wait 30 seconds after applying the developing solution to obtain the results.

Answer and Explanation

Choice A:

Collecting two stool specimens from the same area of the stool is incorrect because specimens should be taken from different areas to ensure a representative sample of the stool for testing.

Choice B:

Using toilet paper to transfer the stool specimen is not recommended as it can contaminate the sample and interfere with test results.

Choice C:

Applying four drops of developing solution to each stool specimen is incorrect. The usual procedure involves applying a specific number of drops as indicated by the test instructions, which may vary.

Choice D:

Waiting 30 seconds after applying the developing solution is correct. This waiting period allows the test to react and provide accurate results for the presence of occult blood.

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ATI NURS125 Maternal Newborn exam

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