a client in labor states i think my water just broke the nurse notes that the umbilical cord is on the perineum what action should the nurse perform f
Logo

Nursing Elites

ATI LPN

ATI Medical Surgical Proctored Exam 2019 Quizlet

1. A client in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?

Correct answer: C

Rationale: In this scenario, the priority action for the nurse is to place the client in Trendelenburg position. This position helps alleviate pressure on the umbilical cord, preventing compression and ensuring continued blood flow to the fetus. Administering oxygen, notifying the operating room team, or administering a fluid bolus are not the initial priority actions in a cord prolapse situation.

2. When should surgical correction of hypospadias typically occur for a newborn infant as advised by the nurse?

Correct answer: B

Rationale: Surgical repair of hypospadias is recommended to be performed before the child is potty-trained to prevent complications. Early correction helps in achieving better outcomes and reduces the risk of issues related to urination and development of the genitalia.

3. A client with portal hypertension who has developed ascites is scheduled for a paracentesis. What pre-procedure nursing intervention is essential?

Correct answer: A

Rationale: Emptying the bladder before a paracentesis is essential to prevent bladder injury during the procedure. A full bladder may be in the path of the needle insertion, increasing the risk of bladder puncture. Encouraging the client to empty the bladder ensures their safety and reduces the likelihood of complications.

4. When creating a care plan for a 70-year-old obese client admitted to the postsurgical unit following a colon resection, the client's age and increased body mass index put them at increased risk for which complication in the postoperative period?

Correct answer: D

Rationale: Infection is a significant risk in obese, elderly clients due to decreased immunity and increased healing time, making them more susceptible to postoperative infections. Proper infection prevention measures should be a priority in the care plan for this client to minimize this risk.

5. In a patient with chronic kidney disease (CKD) receiving erythropoietin therapy, what laboratory result should the nurse monitor to evaluate the effectiveness of this therapy?

Correct answer: C

Rationale: The correct answer is C: Hemoglobin level. Erythropoietin therapy is used to stimulate red blood cell production in patients with chronic kidney disease who often develop anemia due to reduced erythropoietin production by the kidneys. Monitoring the hemoglobin level is essential to evaluate the effectiveness of erythropoietin therapy as an increase in hemoglobin indicates improved red blood cell production and better management of anemia in these patients. Serum creatinine, white blood cell count, and serum potassium levels are important parameters to monitor in CKD patients but are not specific indicators of the effectiveness of erythropoietin therapy for managing anemia.

Similar Questions

A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?
A 75-year-old patient is admitted for pancreatitis. Which tool would be the most appropriate for the nurse to use during the admission assessment?
A client who has just started taking levodopa-carbidopa (Sinemet) for Parkinson's disease reports experiencing nausea. What should the nurse recommend to the client?
A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which side effect should the nurse monitor for?
A patient with chronic obstructive pulmonary disease (COPD) is prescribed tiotropium. What is the primary purpose of this medication?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses