a nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contractures
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. A client who is immobile needs interventions to prevent contractures. Which of the following interventions is appropriate?

Correct answer: C

Rationale: Applying an orthotic to the client's foot is the appropriate intervention to prevent contractures in an immobile client. An orthotic helps maintain proper alignment and prevents the development of contractures by keeping the foot in the correct position. Choices A, B, and D are incorrect because a trochanter wedge, towel roll under the neck, and pillow under the knees are not specific interventions for preventing contractures in an immobile client.

2. What are the potential complications of a patient receiving total parenteral nutrition (TPN)?

Correct answer: A

Rationale: Infection and electrolyte imbalance are common complications of TPN. Infection can occur due to the invasive nature of TPN, which provides a direct route for pathogens. Electrolyte imbalances can arise from the composition of the TPN solution or improper monitoring. Hyperglycemia and sepsis (Choice B) are potential complications but are not as directly associated with TPN as infection and electrolyte imbalance. Kidney failure and hypovolemia (Choice C) are less common complications of TPN. Fluid overload and liver damage (Choice D) are potential complications but are not as frequently observed as infection and electrolyte imbalance.

3. What is the role of a nurse in managing a patient with acute kidney injury (AKI)?

Correct answer: A

Rationale: The correct answer is A: 'Monitor urine output and electrolyte levels.' In managing a patient with acute kidney injury (AKI), it is crucial for the nurse to monitor urine output and electrolyte levels to assess kidney function and the patient's fluid and electrolyte balance. This monitoring helps in early detection of any worsening kidney function or electrolyte imbalances. Choice B is incorrect because administering diuretics and restricting potassium may not be appropriate for all AKI patients and should be done under the direction of a healthcare provider. Choice C is also incorrect as providing dietary education and monitoring fluid intake are important but do not directly address the immediate management of AKI. Choice D is incorrect as administering antibiotics and checking for dehydration are not primary interventions for managing AKI; antibiotics are only given if there is an infection contributing to AKI, and dehydration should be managed but is not the primary role of the nurse in AKI management.

4. What are common signs of hypoglycemia?

Correct answer: A

Rationale: The correct signs of hypoglycemia include shakiness or tremors, sweating, and hunger. These symptoms indicate low blood sugar levels. Confusion or irritability are more associated with severe hypoglycemia, while the immediate treatment for hypoglycemia involves providing a source of glucose to raise blood sugar levels quickly.

5. What are the nursing responsibilities when administering intravenous (IV) antibiotics?

Correct answer: A

Rationale: When administering IV antibiotics, it is essential for the nurse to verify the antibiotic dosage and check for any allergies the patient may have. This is crucial to ensure that the correct medication is being given at the proper dose and to prevent potential adverse reactions. Choice B is incorrect because administering medication without verification can lead to errors. Choice C is incorrect as it goes against safe medication administration practices. Choice D is incorrect as the focus should be on checking if the patient has allergies to antibiotics, not ensuring the patient is allergic to them.

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