the client has just had a pericardiocentesis which interventions should the nurse implement
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 1

1. After undergoing a pericardiocentesis, which interventions should the nurse implement?

Correct answer: D

Rationale: Following a pericardiocentesis, it is crucial for the nurse to monitor vital signs regularly, evaluate cardiac rhythm, and record the amount of fluid removed as output to detect any complications promptly. These interventions help in ensuring the client's safety and detecting any potential issues early. Therefore, selecting 'All of the above' (Choice D) is the correct answer as it encompasses all the essential interventions required post-pericardiocentesis. Choices A, B, and C are necessary actions to provide comprehensive care and monitor the client effectively.

2. The Army Medical Department has four major functions. Three are prevention, treatment, and evacuation. What is the fourth?

Correct answer: C

Rationale: The correct answer is C, 'Mobilization.' Mobilization is the fourth major function of the Army Medical Department. This involves preparing and organizing medical resources and personnel for deployment during military operations. Choices A, B, and D are incorrect because while they are important aspects in military healthcare, they do not represent the fourth major function of the Army Medical Department as specifically requested in the question.

3. The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?

Correct answer: B

Rationale: The correct answer is to perform active range of motion exercises. When a client is on strict bed rest, performing range of motion exercises is a priority to prevent complications such as thromboembolism and muscle atrophy. Option A may be important but not the priority compared to maintaining mobility. Option C is incorrect because elevating the head of the bed to 45 degrees is not necessary for a client on strict bed rest. Option D, providing a high-fiber diet, is also not the priority intervention compared to ensuring range of motion exercises are performed.

4. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

Correct answer: D

Rationale: When a nurse has developed a close relationship with a dying client's family, it is crucial to provide comprehensive support. Encouraging family discussion of feelings helps them express their emotions and concerns, fostering a sense of relief. Accepting the family's experience of anger without judgment validates their emotions and promotes trust. Facilitating the use of spiritual practices identified by the family acknowledges their beliefs and values, offering comfort and solace. Therefore, all of the above interventions are essential in providing holistic care and support during such a challenging time. Choices A, B, and C each play a vital role in addressing different aspects of the family's emotional and spiritual needs, making option D the correct answer.

5. During the admission interview, which question should the nurse ask the male client diagnosed with aorto-iliac disease?

Correct answer: D

Rationale: The correct answer is D: “Have you experienced any problems having sexual intercourse?” Aorto-iliac disease can lead to impaired blood flow to the pelvis and lower extremities, potentially causing sexual dysfunction. The other choices (A, B, and C) are less relevant to the specific effects of aorto-iliac disease on the client's health. While choice A may relate to discomfort, it does not directly address the impact of the disease on sexual function. Choices B and C are more general and do not specifically target the potential issues related to aorto-iliac disease.

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