the client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change which is the nurses priority intervention
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 5

1. The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. Which is the nurse’s priority intervention?

Correct answer: B

Rationale: The correct answer is B. Pain management is essential before the procedure to ensure the client’s comfort and cooperation during the dressing change. Escorting the client to the physical therapy department (choice A) is not the priority at this time. While obtaining sterile dressing supplies (choice C) is important, ensuring pain management takes precedence. Assisting the client to the bathroom (choice D) is not directly related to the priority intervention of pain management before the whirlpool treatment.

2. Which of the following grains is acceptable for someone with celiac disease?

Correct answer: A

Rationale: The correct answer is A: Rice. Rice is a gluten-free grain, making it safe for individuals with celiac disease. Choices B, C, and D (Rye, Wheat, and Barley) contain gluten and are not suitable for individuals with celiac disease, as gluten can trigger adverse reactions in their bodies.

3. Under the health services support area concept, how is the medical care under the MEDCOM divided?

Correct answer: D

Rationale: The correct answer is D. Under the health services support area concept, the medical care under the MEDCOM is divided into eight geographical areas of responsibility designated as health services support regions, each of which is further subdivided into two or more health service areas. This structure allows for a more organized and efficient delivery of medical care across different regions. Choices A, B, and C are incorrect because they do not accurately describe how medical care under the MEDCOM is divided according to the concept of health services support areas.

4. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: The correct interventions to include in the plan of care for a client with fluid volume deficit are monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. These interventions are crucial for managing and detecting fluid volume changes. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and does not address the key aspects of monitoring and assessing fluid status, making it an incorrect choice.

5. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

Correct answer: C

Rationale: The correct action for the nurse to implement when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. Leaning forward can help bring the heart closer to the chest wall, making it easier to detect the rub. Option A (Notifying the healthcare provider) is incorrect because further assessment is needed before escalating the situation. Option B (Documenting that the pericarditis has resolved) is incorrect as the absence of a friction rub does not necessarily mean resolution. Option D (Preparing to insert a unilateral chest tube) is incorrect as this intervention is not indicated for the absence of a friction rub.

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