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. What is the most crucial and most difficult management skill required of the M6 practical nurse?

Correct answer: D

Rationale: Correct. Effectively managing personnel is indeed the most crucial and difficult management skill required of a practical nurse. This skill involves supervising, motivating, and coordinating the work of other healthcare staff, ensuring optimal patient care. Choices A, B, and C are important tasks but do not necessarily involve the same level of complexity and interpersonal skills required for managing personnel in a healthcare setting.

3. A client with type 1 diabetes is diagnosed with diabetic ketoacidosis and initially treated with intravenous fluids followed by an IV bolus of regular insulin. The nurse anticipates that the practitioner will prescribe a continuous infusion of insulin of:

Correct answer: B

Rationale: The correct answer is Novolin R (Regular insulin) because it is used for continuous infusion to treat diabetic ketoacidosis. Novolin R has a rapid onset of action, making it suitable for this acute situation. Novolin L insulin (Choice A) is not typically used for continuous infusion in diabetic ketoacidosis. Novolin N insulin (Choice C) is an intermediate-acting insulin and is not ideal for rapid correction needed in diabetic ketoacidosis. Novolin U insulin (Choice D) is an ultra-long-acting insulin and is not appropriate for the immediate correction required in this scenario.

4. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

Correct answer: C

Rationale: Correct care for a client in Buck’s traction includes turning the client to the unaffected side to prevent complications such as pressure ulcers. Additionally, asking the client to dorsiflex the foot on the affected leg helps prevent foot drop. Removing the foam boot three times per day to inspect the skin is unnecessary and could disrupt the traction, so it is not appropriate. Therefore, choices A and D are incorrect.

5. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires immediate intervention?

Correct answer: D

Rationale: Choice D is the correct answer because a swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition requires immediate intervention to prevent testicular damage. Choices A, B, and C do not present findings that suggest a surgical emergency requiring immediate intervention.

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