the client has just had a pericardiocentesis which interventions should the nurse implement
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 1

1. After undergoing a pericardiocentesis, which interventions should the nurse implement?

Correct answer: D

Rationale: Following a pericardiocentesis, it is crucial for the nurse to monitor vital signs regularly, evaluate cardiac rhythm, and record the amount of fluid removed as output to detect any complications promptly. These interventions help in ensuring the client's safety and detecting any potential issues early. Therefore, selecting 'All of the above' (Choice D) is the correct answer as it encompasses all the essential interventions required post-pericardiocentesis. Choices A, B, and C are necessary actions to provide comprehensive care and monitor the client effectively.

2. The nurse writes a problem of “potential for complication related to ovarian hyperstimulation” for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?

Correct answer: B

Rationale: Frequent pelvic sonograms help monitor for ovarian hyperstimulation, a serious potential side effect of clomiphene. Instructing the client to delay intercourse until menses (choice A) is not directly related to monitoring or managing ovarian hyperstimulation. Explaining the duration of infusion therapy (choice C) is not relevant to the potential complication of ovarian hyperstimulation. Discussing the risk of ectopic pregnancy (choice D) is important but not the most appropriate intervention for managing ovarian hyperstimulation.

3. The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

Correct answer: D

Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.

4. Management experience prepares the practical nurse to be a Clinical NCO or a Senior Clinical NCO. These positions are normally held by which of the following?

Correct answer: C

Rationale: The correct answer is C: E6, E7, or E8. Clinical NCO or Senior Clinical NCO positions are typically held by individuals at the E6, E7, or E8 pay grades in the military. These positions require a higher level of experience and leadership, which align with the ranks of E6, E7, or E8. Choices A, B, and D are incorrect because Army Nurse Corps officers, First Sergeants, E3, E4, or E5 are not the typical ranks that hold Clinical NCO positions.

5. A client takes an antidepressant and oral contraceptives. Which herbal supplement should the nurse educate the client about as a potential drug-herb interaction?

Correct answer: D

Rationale: St. John’s Wort is the correct answer because it can interact with antidepressants and oral contraceptives, potentially affecting their efficacy. Iron supplement, garlic, and green tea do not typically interact with antidepressants or oral contraceptives to the same extent as St. John’s Wort.

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