the nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy which intervention should the nurse implem

ATI RN

ATI RN Custom Exams Set 1

1. The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

A. Establish a rapport with the client to decrease embarrassment during site assessment
B. Encourage the client to lie in the lithotomy position twice a day
C. Milk the tube inserted during surgery to facilitate the passage of flatus
D. Digitally dilate the rectal sphincter to express old blood

Correct answer: A

Rationale: Establishing rapport with the client is crucial in postoperative care to create a trusting relationship, reduce embarrassment, and enhance comfort during assessments. Encouraging the client to lie in the lithotomy position is not recommended after a hemorrhoidectomy as it can be uncomfortable and may disrupt wound healing. Milking the tube inserted during surgery is not a standard practice and could lead to complications. Digitally dilating the rectal sphincter is not indicated post-hemorrhoidectomy and can cause harm to the client.

2. A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?

A. Obtain a court order for the surgery
B. Sign the informed consent on behalf of the client
C. Send the client to surgery without the consent form being signed
D. Obtain a telephone consent from a family member, with the consent being witnessed by two healthcare providers

Correct answer: D

Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member witnessed by two healthcare providers is the appropriate action to ensure informed consent is obtained. Option A is not necessary and involves legal proceedings. Option B is not ethical as the nurse cannot sign the consent on behalf of the client. Option C is unsafe and violates the client's rights by proceeding without proper consent.

3. Which situation(s) are classified as natural disasters?

A. Blizzards
B. Blizzards, Volcanic eruptions
C. Volcanic eruptions
D. Structural collapse

Correct answer: B

Rationale: Blizzards and volcanic eruptions are classified as natural disasters because they are caused by natural forces beyond human control. In contrast, structural collapses are typically a result of man-made factors, making them not classified as natural disasters. Therefore, the correct answer is B.

4. The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion?

A. Start the transfusion at 10-15 mL per hour for 15-30 minutes
B. Re-crossmatch the blood until the antibodies are identified
C. Have the client sign a permit to receive uncrossmatched blood
D. Have the unlicensed nursing assistant stay with the client

Correct answer: A

Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is the correct precaution to implement when the cross-match reveals the presence of antibodies that cannot be cross-matched. This allows the nurse to monitor for any adverse reactions due to the presence of antibodies. Re-crossmatching the blood until the antibodies are identified is not practical and may delay the transfusion, potentially compromising the patient's condition. Having the client sign a permit to receive uncrossmatched blood is not the best course of action as the focus should be on ensuring a safe transfusion. Having an unlicensed nursing assistant stay with the client does not address the specific precaution needed to manage a transfusion in the presence of antibodies.

5. In which situation(s) can personal health information be disclosed?

A. Compliance with legal proceedings
B. For research purposes in limited circumstances
C. To a family member or significant other in an emergency
D. All of the above

Correct answer: D

Rationale: Personal health information can be disclosed in various situations. Compliance with legal proceedings allows for disclosure under specific legal requirements. Disclosure for research purposes is permitted in limited circumstances with appropriate approvals. In emergencies, information can be shared with family members or significant others. Therefore, all of the choices are correct as they represent valid scenarios for disclosing personal health information.