the nurse is assessing a client before surgery which assessments contraindicate the client from having surgery as scheduled select one that does not a
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Nursing Elites

ATI RN

Endocrinology Exam

1. The healthcare provider is assessing a client before surgery. Which assessments contraindicate the client from having surgery as scheduled? (Select one that does not apply.)

Correct answer: C

Rationale: The correct answer is C: Prothrombin time (PT) of 30 seconds. A low potassium level (choice A) and an elevated INR (choice B) indicate potential bleeding risks during surgery. A positive pregnancy test (choice D) in a female client can lead to complications during surgery. However, a Prothrombin time of 30 seconds is within the normal range and does not contraindicate the client from having surgery as scheduled.

2. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?

Correct answer: D

Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.

3. A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts the nurse to the possibility of a complication from the UTI?

Correct answer: C

Rationale: Fever and chills are systemic symptoms that may indicate a more severe infection or a complication of a urinary tract infection (UTI). While burning on urination and cloudy, dark urine are common symptoms of UTI, fever and chills suggest a more serious condition requiring immediate attention. Hematuria, which is blood in the urine, is also a concerning symptom but is more indicative of inflammation or infection rather than a complication.

4. A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?

Correct answer: C

Rationale: Ensuring the safety of a blood transfusion is crucial to prevent potential errors or adverse reactions. Checking the blood identification numbers with the laboratory technician at the Blood Bank when the blood is dispersed helps confirm that the correct blood product is being administered to the right patient, reducing the risk of transfusion reactions. The other choices are incorrect because asking the client to say and spell their full name (Choice A) is a part of the identification process but not specific to ensuring the safety of the blood transfusion. While having another qualified healthcare professional check the unit (Choice B) is a good practice, the direct verification with the Blood Bank technician is a more critical step in ensuring the correct blood product is administered. Choice D is irrelevant to ensuring the safety of the blood transfusion as it addresses infection control measures.

5. When the client finds antiembolism stockings uncomfortably tight, what is the nurse's best action?

Correct answer: D

Rationale: The correct action for the nurse to take when a client finds antiembolism stockings uncomfortably tight is to teach the client the purpose of wearing the stockings. This educates the client on the importance of the stockings in preventing blood clots and encourages compliance. Removing the stockings or pulling them down may compromise their effectiveness. Measuring the client's calf size is not necessary in this situation as the discomfort is due to tightness, not incorrect sizing.

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