a nurse is caring for a client who is acutely ill and has included vigilant oral care in the clients plan of care what factor increases this clients r
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Nursing Elites

ATI LPN

Medical Surgical ATI Proctored Exam

1. A client who is acutely ill has vigilant oral care included in their plan of care. What factor increases this client's risk for dental caries?

Correct answer: D

Rationale: Inadequate nutrition and decreased saliva production can lead to a conducive environment for the development of dental caries. Without proper nutrition and sufficient saliva, the protective mechanisms against cavities are compromised, making the individual more susceptible to tooth decay.

2. A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client?

Correct answer: D

Rationale: The correct answer is 'Risk for injury.' In a client with dementia who is disoriented, wandering, and experiencing sleep disturbances, the priority nursing problem is the risk for injury. Disorientation and wandering behavior can lead to accidents, falls, or other harmful situations, making it crucial for the nurse to address the safety concerns first to prevent any potential harm to the client.

3. A client with liver cirrhosis and ascites is being treated with spironolactone. What is a key nursing consideration for this medication?

Correct answer: A

Rationale: Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia as it helps retain potassium in the body. Therefore, monitoring for signs of hyperkalemia such as muscle weakness, arrhythmias, or ECG changes is crucial to prevent potential complications.

4. A client with a history of myocardial infarction (MI) is prescribed nitroglycerin (Nitrostat) for chest pain. Which instruction should the nurse provide?

Correct answer: D

Rationale: The correct instruction for a client prescribed nitroglycerin (Nitrostat) for chest pain is to place the tablet under the tongue. This route allows for rapid absorption of the medication, providing quick relief for chest pain associated with myocardial infarction.

5. A patient with hyperthyroidism is prescribed propylthiouracil (PTU). What is the primary purpose of this medication?

Correct answer: B

Rationale: Propylthiouracil (PTU) is a medication used to treat hyperthyroidism by suppressing the production of thyroid hormones. It works by inhibiting the enzyme responsible for the synthesis of thyroid hormones, thereby reducing their levels in the body. This helps to alleviate the symptoms of hyperthyroidism and restore thyroid hormone levels to normal range.

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