a nurse is planning care for a client who is postoperative following abdominal surgery which of the following interventions should the nurse implement
Logo

Nursing Elites

ATI RN

ATI Exit Exam RN

1. A nurse is planning care for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse implement to prevent respiratory complications?

Correct answer: C

Rationale: The correct answer is C. Encouraging the client to use an incentive spirometer every hour is crucial to prevent respiratory complications postoperatively. Incentive spirometry helps in lung expansion and prevents atelectasis, which is common after abdominal surgery. Choice A, encouraging ambulation, is important for preventing complications but does not directly address respiratory issues. Choice B, deep breathing and coughing every hour, is also beneficial but not as effective in preventing atelectasis as using an incentive spirometer. Choice D, instructing the client to avoid coughing, is incorrect as coughing helps clear secretions and prevent respiratory complications.

2. While caring for a client with an arterial line, which of the following actions should the nurse take?

Correct answer: C

Rationale: Obtaining arterial blood gases is a crucial nursing action when caring for a client with an arterial line. This procedure helps assess the client's oxygenation status and acid-base balance accurately. Leveling the transducer with the client's phlebotomy site (A) is important for accurate pressure measurements, but it is not the primary action in this scenario. Flushing the arterial line every 8 hours (B) is a routine maintenance procedure and not the immediate priority. Keeping the client's hand elevated above the heart level (D) is a good practice to prevent swelling, but it is not directly related to the arterial line care in this case.

3. A healthcare provider is assessing a client who is receiving chemotherapy and reports mouth sores. Which of the following findings should the healthcare provider expect?

Correct answer: C

Rationale: White patches on the tongue are a sign of oral candidiasis, a common side effect of chemotherapy. This fungal infection can result in the development of white patches on the tongue. Dry, cracked lips (choice A) are more indicative of dehydration or lack of moisture. Red, swollen gums (choice B) may be a sign of gingivitis or periodontal disease. Pale, dry mouth (choice D) is not typically associated with mouth sores from chemotherapy.

4. 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.

5. A client with type 1 diabetes mellitus is being taught self-administration of insulin by a nurse. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct instruction the nurse should include is to rotate injection sites within the same anatomical region. This practice helps reduce the risk of lipodystrophy, a condition characterized by fatty tissue changes due to repeated insulin injections in the same spot. By rotating sites, the client ensures better insulin absorption and prevents localized skin changes. Injecting air into the vial before withdrawing insulin (Choice A) is unnecessary and not recommended. Drawing up short-acting insulin before long-acting insulin (Choice B) is not a standard practice and can lead to errors in dosing. Storing unopened insulin vials in the freezer (Choice C) is incorrect as insulin should be stored in the refrigerator, not the freezer, to maintain its effectiveness.

Similar Questions

A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider?
A healthcare professional is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the professional make in the medical record?
When using an IV pump for a newly admitted client, what action should the nurse take?
A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?
Which electrolyte imbalance should be closely monitored in a patient receiving digoxin?

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