a nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease ckd which of the following referrals should the nurse pla

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate?

A. Respiratory therapy
B. Hospice care
C. Occupational therapy
D. Dietary services

Correct answer: D

Rationale: The correct answer is D: Dietary services. Referring the client to dietary services is essential for managing nutrition, including monitoring sodium, potassium, and protein intake, which are crucial aspects of managing chronic kidney disease (CKD). Respiratory therapy (choice A) focuses on managing respiratory conditions, which are not directly related to CKD. Hospice care (choice B) is not appropriate for a new diagnosis of CKD as it is designed for end-of-life care. Occupational therapy (choice C) is beneficial for improving activities of daily living but is not the priority referral for a new CKD diagnosis.

2. A patient who received an enema reports abdominal cramping. What should the nurse do?

A. Increase the flow of the enema solution
B. Lower the height of the enema solution container
C. Remove the enema tubing
D. Stop the procedure

Correct answer: B

Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.

3. What should be taught to a patient following cataract surgery?

A. Avoid NSAIDs
B. Wear dark glasses when outdoors
C. Report green or yellow drainage immediately
D. Itching is normal unless accompanied by pain and nausea

Correct answer: A

Rationale: The correct answer is to avoid NSAIDs after cataract surgery to reduce the risk of bleeding. Choice B, wearing dark glasses when outdoors, is generally recommended after cataract surgery to protect the eyes from bright sunlight, but it is not the most critical instruction. Choice C, reporting green or yellow drainage immediately, is important to monitor for signs of infection, but it is not specific to cataract surgery. Choice D, itching is normal unless accompanied by pain and nausea, is not the most crucial advice post-cataract surgery. Therefore, the key instruction is to avoid NSAIDs to minimize bleeding risk.

4. What should the nurse monitor for in a patient with hypokalemia?

A. Monitor for muscle weakness
B. Check deep tendon reflexes (DTRs)
C. Monitor for seizures
D. Monitor for bradycardia

Correct answer: A

Rationale: The correct answer is to monitor for muscle weakness in a patient with hypokalemia. Hypokalemia, which is low potassium levels, can lead to muscle weakness due to its effects on neuromuscular function. Checking deep tendon reflexes (Choice B) is not typically associated with hypokalemia. Seizures (Choice C) are more commonly associated with low calcium levels rather than low potassium levels. Bradycardia (Choice D) is a symptom of hyperkalemia (high potassium levels) rather than hypokalemia.

5. During an escharotomy on a patient with a burn injury, what is the purpose of this procedure?

A. To release pressure and improve circulation in the affected area
B. To remove dead tissue from the burn area
C. To improve breathing by reducing skin tightness
D. To prevent infection in the burned area

Correct answer: A

Rationale: Corrected Question: During an escharotomy on a patient with a burn injury, the purpose of this procedure is to release pressure and improve circulation in the affected area. This intervention is crucial in severe burns where the formation of eschar (dead tissue) can lead to increased pressure, compromising circulation and potentially causing further tissue damage. Choices B, C, and D are incorrect because escharotomy specifically aims to address pressure and circulation issues in severe burn injuries, rather than removing dead tissue, improving breathing, or preventing infection.