the nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left si
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 1

1. The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?

Correct answer: C

Rationale: Choice C is the best direction provided by the nurse. This method involves reaching over to the left side rail with the right hand, pulling the body onto its side, bending the upper leg so the foot is on the bed, and pushing down to elevate the trunk. This approach helps maintain spinal alignment while moving from a lying to a standing position, reducing strain on the back. Choices A, B, and D involve movements that are not suitable for a client recovering from a lumbar laminectomy with spinal fusion and could potentially cause harm or discomfort.

2. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?

Correct answer: A

Rationale: The correct answer is A because removing sequential compression devices could increase the risk of thromboembolism, making it the priority. Choice B involves assisting with ambulation, which can be done after addressing the urgent need of the client in choice A. Choice C and D involve non-urgent tasks compared to the potential risks associated with not removing sequential compression devices promptly.

3. In determining and fulfilling the nursing care needs of the patient, which step involves assessing whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status?

Correct answer: A

Rationale: The correct answer is A, 'Evaluation.' Evaluation in nursing involves assessing whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status. This step helps determine the outcomes of the care provided and if any changes are needed. Choice B, 'Planning,' focuses on developing a plan of care based on the assessment findings. Choice C, 'Implementation,' involves carrying out the plan of care. Choice D, 'Assessment,' is the initial step in the nursing process that involves gathering data about the patient's health status.

4. Which discharge instruction should the nurse provide to the client diagnosed with varicose veins who has received sclerotherapy?

Correct answer: A

Rationale: The correct answer is to instruct the client to walk 15 to 20 minutes three times a day. Walking helps improve circulation and reduces the risk of complications following sclerotherapy. Choice B, keeping the legs in the dependent position when sitting, is incorrect as it can increase venous pressure. Choice C, removing compression bandages before going to bed, is incorrect as compression should be maintained as per healthcare provider's instructions. Choice D, performing Berger-Allen exercises four times a day, is incorrect as these exercises may not be specifically recommended post-sclerotherapy.

5. Determining nursing care priorities is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

Correct answer: B

Rationale: Corrected Rationale: Planning in nursing involves setting priorities based on the identified patient needs, establishing goals, and developing a plan of care. Evaluation involves assessing the effectiveness of the care provided, implementation is the phase where the care plan is carried out, and assessment is the initial step of collecting data to identify the patient's needs. Therefore, in the context of determining nursing care priorities, the correct step is Planning (choice B).

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