a nurse is caring for a client who is 1 day postoperative following a hip arthroplasty which of the following actions should the nurse take to prevent
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Nursing Elites

ATI RN

ATI RN Exit Exam Quizlet

1. A patient is 1 day postoperative following a hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the hip?

Correct answer: B

Rationale: Placing a pillow between the patient's legs is the correct action to prevent dislocation of the hip following arthroplasty. This technique helps maintain proper alignment and stability of the hip joint. Keeping the patient in a side-lying position may not provide the necessary support to prevent hip dislocation. Instructing the patient to avoid sitting for long periods is important for preventing complications like deep vein thrombosis but does not directly prevent hip dislocation. Elevating the head of the bed to 90 degrees is not relevant to preventing hip dislocation in a postoperative hip arthroplasty patient.

2. A nurse is preparing to administer a dose of amoxicillin to a client who has an allergy to penicillin. Which of the following actions should the nurse take?

Correct answer: C

Rationale: In this scenario, the nurse should ask the provider to prescribe a different antibiotic instead of administering amoxicillin to a client with a known penicillin allergy. Choice A is incorrect because administering amoxicillin to a client with a penicillin allergy can lead to an allergic reaction. Choice B is not the best option as simply verifying the client's allergy status does not address the potential harm of giving amoxicillin. Choice D is irrelevant as checking the client's skin for rashes does not address the issue of administering a potentially harmful medication. Therefore, the most appropriate action is to request a different antibiotic from the provider to ensure the safety of the client.

3. A nurse is providing teaching to a client who is at 36 weeks of gestation and is scheduled for a nonstress test. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is D. A nonstress test measures the fetal heart's response to movement, helping to assess fetal well-being. Choice A is incorrect as the duration of the test can vary, and it is not always precisely 30 minutes. Choice B is incorrect as drinking water is not necessary for a nonstress test. Choice C is incorrect as having a full bladder is not required for this test.

4. A nurse is teaching a client who has a new diagnosis of diabetes mellitus about managing blood glucose levels. Which of the following client statements indicates an understanding of the teaching?

Correct answer: C

Rationale: Taking insulin at the same time each day helps maintain stable blood glucose levels and prevent complications.

5. A client is receiving intermittent tube feedings and is at risk for aspiration. What should the nurse identify as a risk factor?

Correct answer: B

Rationale: The correct answer is B: History of gastroesophageal reflux disease. Gastroesophageal reflux disease increases the risk of aspiration due to the potential for regurgitation of stomach contents into the esophagus and airways. Choices A, C, and D are not directly related to an increased risk of aspiration. A residual of 65mL 1 hour postprandial may indicate delayed gastric emptying but is not a direct risk factor for aspiration. Receiving a high-osmolarity formula or receiving a feeding in a supine position are not specific risk factors for aspiration unless they contribute to reflux or other related issues.

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