the nurse is caring for a client diagnosed with rule out nephritic syndrome which intervention should be included in the plan of care

ATI RN

ATI RN Custom Exams Set 5

1. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

A. Monitor the urine for bright-red bleeding
B. Evaluate the calorie count of the 500-mg protein diet
C. Assess the client’s sacrum for dependent edema
D. Monitor for a high serum albumin level

Correct answer: C

Rationale: The correct intervention to include in the plan of care for a client with rule-out nephritic syndrome is to assess the client’s sacrum for dependent edema. Dependent edema is common in nephritic syndrome due to protein loss, and monitoring for this helps manage the condition. Choices A, B, and D are incorrect. Monitoring the urine for bright-red bleeding may be more relevant for a client with a different condition, such as glomerulonephritis. Evaluating the calorie count of a 500-mg protein diet is not directly related to managing nephritic syndrome. Monitoring for a high serum albumin level does not directly address the symptom of dependent edema associated with nephritic syndrome.

2. Three major causes of atherosclerosis are:

A. Hyperthyroidism, underweight, and poor appetite
B. High blood cholesterol, high blood pressure, and cigarette smoking
C. Constipation, peptic ulcer disease, and pancreatitis
D. Kidney failure, edema, and sodium retention

Correct answer: B

Rationale: Atherosclerosis is primarily caused by high blood cholesterol, high blood pressure, and cigarette smoking. These factors contribute to the buildup of plaque in the arteries. Choices A, C, and D are incorrect. Hyperthyroidism, underweight, and poor appetite do not directly cause atherosclerosis. Similarly, constipation, peptic ulcer disease, pancreatitis, kidney failure, edema, and sodium retention are not among the primary causes of atherosclerosis.

3. The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?

A. Encourage the client to drink liquids
B. Perform active range of motion exercises
C. Elevate the head of the bed to 45 degrees
D. Provide a high-fiber diet to the client

Correct answer: B

Rationale: Performing active range of motion exercises is the priority intervention for a client on strict bed rest. These exercises help prevent complications such as thromboembolism and muscle atrophy by promoting circulation and maintaining muscle strength. Encouraging liquids, elevating the head of the bed, and providing a high-fiber diet are important interventions but not the priority when compared to preventing serious complications associated with immobility.

4. Short-bowel syndrome usually occurs when:

A. The longitudinal muscles of the intestine contract
B. More than 50% of the small intestine is surgically removed
C. More than 50% of the large intestine is surgically removed
D. Transit time is decreased due to infection or drugs

Correct answer: B

Rationale: Short-bowel syndrome usually occurs when more than 50% of the small intestine is surgically removed. This condition results in malabsorption of nutrients and fluids due to the reduced length of the small intestine. Choice A is incorrect because the contraction of longitudinal muscles does not lead to short-bowel syndrome. Choice C is incorrect as short-bowel syndrome is primarily related to the small intestine, not the large intestine. Choice D is incorrect since decreased transit time due to infection or drugs is not a direct cause of short-bowel syndrome.

5. The client diagnosed with acute vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

A. Discontinue the heparin drip prior to initiating the Coumadin
B. Check the client’s INR prior to beginning Coumadin
C. Clarify the order with the health care provider as soon as possible
D. Administer the Coumadin along with the heparin drip as ordered

Correct answer: D

Rationale: The correct action for the nurse to take is to administer the Coumadin along with the heparin drip as ordered. Heparin and warfarin are often given together initially because warfarin takes a few days to become effective. Discontinuing the heparin drip prior to initiating Coumadin could leave the patient without anticoagulation coverage during the period when warfarin's effects are not yet established. Checking the client's INR prior to beginning Coumadin is important but not the immediate action to take when both medications are ordered together. Clarifying the order with the health care provider is unnecessary in this scenario as it is common practice to give heparin and warfarin concurrently in the transition period.