a nurse is caring for a client who is postoperative following a colon resection and reports pain which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A client who is postoperative following a colon resection reports pain. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Administering a PRN dose of morphine is the most appropriate action to manage postoperative pain in a client following a colon resection. Morphine is a potent analgesic commonly used to relieve moderate to severe pain, especially in postoperative settings. While assisting the client to change positions in bed, encouraging relaxation techniques, and offering a back massage can provide comfort and support, they may not be sufficient in managing the pain following a major surgical procedure like a colon resection. Therefore, the priority intervention for acute postoperative pain control in this scenario is to administer medication like morphine.

2. A nurse is providing teaching to a client who has been prescribed digoxin for heart failure. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Check your pulse before taking this medication.' When a patient is prescribed digoxin, it is crucial to monitor their pulse rate because digoxin can cause bradycardia (slow heart rate) as a side effect. In contrast, choices A, C, and D are incorrect. Taking digoxin with meals is not necessary; it should be taken consistently at the same time every day. Taking digoxin with an antacid is not recommended as it can interfere with the absorption of the medication. While digoxin can cause hypokalemia (low potassium levels), patients should not increase their potassium intake without healthcare provider guidance to avoid potential complications.

3. A nurse is caring for a client who is scheduled for a colonoscopy. Which of the following findings should the nurse report to the provider?

Correct answer: A

Rationale: The correct answer is A. Ibuprofen is an NSAID that can increase the risk of bleeding during a colonoscopy due to its effects on platelet function. It is important to report this finding to the provider to consider alternative pain management options. Choices B, C, and D are not the most pertinent to report for a colonoscopy. Asthma and a history of diverticulitis are relevant medical history but do not directly impact the colonoscopy procedure. Drinking one glass of wine daily is not a concern specifically related to the colonoscopy procedure.

4. A nurse is caring for a client who has received a new diagnosis of terminal cancer. The client tells the nurse, 'I just want to live long enough to see my child graduate.' The nurse should identify that the client is in which of the following stages of grief?

Correct answer: B

Rationale: The client expressing a desire to live long enough to see their child graduate is an example of bargaining, which is a stage of grief where individuals attempt to negotiate for more time or different outcomes. Denial refers to refusing to accept the reality of the situation, acceptance involves coming to terms with the diagnosis, and anger is feeling frustrated and upset about the situation. Therefore, the correct answer is 'Bargaining.'

5. A client with diabetes mellitus is being taught by a nurse about preventing long-term complications. Which of the following client statements indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because checking the feet daily for open sores or wounds is crucial in preventing complications like diabetic foot ulcers. While maintaining blood glucose levels within the target range (choice A) is important in managing diabetes, it does not specifically address long-term complications. Consuming foods high in fiber (choice C) is beneficial for glycemic control but does not directly relate to preventing long-term complications. Monitoring blood pressure regularly (choice D) is important in managing diabetes but is not as directly related to preventing long-term complications as checking for foot wounds.

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