a nurse is caring for a client who is receiving morphine for pain management which of the following findings indicates the client is experiencing an a
Logo

Nursing Elites

ATI RN

ATI Exit Exam 2023

1. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

Correct answer: C

Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.

2. A nurse is planning care for a client who has a new prescription for warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the therapy?

Correct answer: C

Rationale: Corrected Rationale: The nurse should monitor the client's INR to determine the effectiveness of warfarin therapy. INR monitoring is crucial as it reflects the blood's ability to clot properly. Warfarin is commonly used as an anticoagulant, and maintaining the INR within the therapeutic range ensures that the client is protected from both clotting and bleeding events. Monitoring serum calcium levels, platelet count, or WBC count is not directly related to assessing the effectiveness of warfarin therapy.

3. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?

Correct answer: A

Rationale: In a client who is 30 minutes postoperative following an arterial thrombectomy, chest pain is a critical finding that should be reported immediately. Chest pain can indicate serious complications such as myocardial infarction or pulmonary embolism, which require prompt intervention. Muscle spasms and cool, moist skin are not typical signs of immediate concern following an arterial thrombectomy. Incisional pain is expected postoperatively and may not warrant immediate reporting unless accompanied by other concerning symptoms.

4. A nurse is caring for a client who is receiving continuous enteral feeding through a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?

Correct answer: C

Rationale: To prevent aspiration in clients receiving continuous enteral feedings, the nurse should elevate the head of the bed to 45 degrees. This position helps reduce the risk of regurgitation and aspiration. Flushing the tube with water every 4 hours (Choice A) is important for maintaining tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (Choice B) is not specifically related to preventing aspiration in this context. Checking gastric residual every 2 hours (Choice D) is important to assess feeding tolerance but does not directly prevent aspiration.

5. A client has thrombocytopenia. What action should the nurse include?

Correct answer: C

Rationale: The correct action for the nurse when caring for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is characterized by a low platelet count, leading to increased bleeding tendencies. Providing a stool softener helps prevent constipation, reducing the likelihood of straining during bowel movements and subsequent bleeding. Encouraging the client to floss daily (choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (choice B) pertains more to infection control than addressing thrombocytopenia. Avoiding serving raw vegetables (choice D) is not directly associated with managing thrombocytopenia symptoms.

Similar Questions

A nurse is planning care for a client who has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan of care?
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following client statements indicates an understanding of the teaching?
A nurse is assessing a client who has a history of urinary incontinence. Which of the following findings should the nurse report to the provider?
A healthcare professional is reviewing the laboratory values of a client who has cirrhosis. Which of the following findings should the healthcare professional report to the provider?
A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

Access More Features

ATI RN Basic
$69.99/ 30 days

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

ATI RN Premium
$149.99/ 90 days

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

Other Courses