protecting the rights and privacy of the patient and his family is a part of which of the following steps for determining and fulfilling the nursing
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. Protecting the rights and privacy of the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

Correct answer: C

Rationale: The correct answer is C: Implementation. Implementation is the phase where the nursing care plan is put into action, which includes safeguarding the patient's and their family's rights and privacy. Evaluation (choice A) involves reviewing the effectiveness of the care plan, Planning (choice B) is the phase where the care plan is developed, and Assessment (choice D) is the initial step where data about the patient is collected.

2. The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?

Correct answer: D

Rationale: In a sickle cell crisis, morphine is the preferred analgesic due to its potency and effectiveness in managing severe pain. Choice A is incorrect because aspirin is contraindicated in sickle cell disease due to its potential to cause a further decrease in blood flow. Choice B, Motrin (ibuprofen), is also not the ideal choice as NSAIDs can exacerbate renal complications in sickle cell patients. Choice C, Demerol (meperidine), is not recommended for sickle cell pain management due to its toxic metabolite accumulation which can cause seizures and other complications.

3. What intervention should the nurse implement for the client who has an ileal conduit?

Correct answer: C

Rationale: The correct intervention for a client with an ileal conduit is to report any decrease in urinary output to the healthcare provider. Decreased urinary output in these clients may indicate a blockage or another complication, which requires immediate attention. Monitoring the stoma for signs of infection (Choice D) is important but not the priority when compared to a decrease in urinary output. Pouching the stoma with a one-inch margin around it (Choice A) is incorrect as it does not address the issue of decreased urinary output. Referring the client to the United Ostomy Association (Choice B) is not necessary in this immediate situation where a potential complication is suspected.

4. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

Correct answer: A

Rationale: A consultation with a Rapid Response Team (RRT) is most appropriate for the 45-year-old client described in Choice A. This client is 2 years post kidney transplant, presenting with no urine output for 6 hours, a temperature of 101.4°F, heart rate of 98 beats per minute, respirations of 20 breaths per minute, and a blood pressure of 88/72 mm Hg, along with restlessness. These clinical signs are indicative of possible acute renal failure and sepsis, requiring immediate intervention by the rapid response team. Choices B, C, and D do not present the same level of urgency and severity of symptoms as the client in Choice A, making them less appropriate for consultation with the RRT.

5. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Albumin increases the circulating blood volume, which helps to reduce ascites and improve hemodynamics in clients with portal hypertension. Choice A is incorrect because salt-poor albumin is not primarily administered to provide nutrients. Choice B is incorrect because the main purpose of administering albumin is not to increase protein stores but to address fluid shifts. Choice D is incorrect because administering albumin does not divert blood flow away from the liver temporarily; instead, it helps improve blood volume and circulation.

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