a nurse is planning care for a client who has a closed head injury and has an intraventricular catheter which of the following interventions should th
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. A nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?

Correct answer: D

Rationale: The correct answer is to monitor the insertion site for redness. This intervention helps detect signs of infection early in clients with intraventricular catheters. Keeping the head of the bed elevated to 30 degrees is important for managing intracranial pressure but does not directly reduce the risk of infection. Administering IV antibiotics prophylactically is not recommended as a routine practice due to the risk of antibiotic resistance and should only be done based on culture results. Changing the catheter insertion site every 24 hours is unnecessary and increases the risk of introducing new pathogens.

2. A client with heart failure has a new prescription for furosemide. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B. Clients taking furosemide, a potassium-wasting diuretic, should increase their intake of potassium-rich foods to prevent hypokalemia. Option A is incorrect because weight monitoring is crucial for furosemide due to fluid loss. Option C is incorrect as furosemide is usually taken in the morning to prevent nighttime diuresis. Option D is incorrect because furosemide is best taken on an empty stomach for better absorption.

3. A client has a new prescription for alendronate. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction when taking alendronate is to remain upright for 30 minutes after administration. This helps prevent esophageal irritation, a known side effect of the medication. Option A is incorrect because alendronate should be taken in the morning on an empty stomach. Option B is incorrect as taking alendronate with food decreases its absorption. Option D is incorrect as alendronate should be swallowed whole with a full glass of water and not chewed.

4. During an emergency response following a disaster, which client should be recommended for early discharge?

Correct answer: D

Rationale: The client who is 1 day postoperative following a vertebroplasty is stable and can be discharged early. In an emergency response situation, it is crucial to prioritize clients who are medically stable and do not require immediate hospital care. The client with COPD and a respiratory rate of 44/min needs close monitoring and intervention. The client with cancer and a sealed implant for radiation therapy requires specialized care and follow-up. The client receiving heparin for deep-vein thrombosis needs ongoing anticoagulant therapy and monitoring, making early discharge not appropriate.

5. A nurse is teaching a client who has chronic kidney disease about managing protein intake. Which of the following statements should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D: "You should limit your intake of high-protein foods." Clients with chronic kidney disease should reduce their intake of high-protein foods to lessen the workload on the kidneys and prevent further kidney damage. Choices A, B, and C are incorrect because increasing intake of either plant-based or animal protein or high-protein foods can exacerbate kidney issues in individuals with chronic kidney disease.

Similar Questions

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A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?
Which electrolyte imbalance is commonly associated with patients on furosemide?
A client has a new prescription for metformin. Which of the following client statements indicates an understanding of the teaching?
A nurse is caring for a client who is experiencing dysphagia. Which of the following interventions should the nurse implement?

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