the nurse is caring for the client one 1 day postoperative sigmoid colostomy operation which independent nursing intervention should the nurse implem
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. The nurse is caring for the client one 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 an essential nursing intervention postoperatively as it helps promote circulation, prevent complications like blood clots, and aids in the recovery process. Changing the infusion rate of intravenous fluid (Choice A) requires a physician's order and is not an independent nursing intervention. Encouraging the client to discuss feelings (Choice B) is important for emotional support but not as crucial as physical care immediately postoperatively. Administering opioid narcotic medications (Choice C) for pain management should be based on a prescribed schedule and assessment rather than being an independent nursing action.

2. What is established when threats to air resources prevent evacuation by air from forward units?

Correct answer: C

Rationale: Ambulance exchange points are established when threats to air resources prevent evacuation by air from forward units. These points serve as locations where patients can be transferred between ground and air ambulances. Area support medical battalions (Choice A) refer to medical units that provide medical support to large areas and are not specifically related to evacuation. TOE units (Choice B) and field hospitals (Choice D) are not typically established in response to threats to air resources affecting evacuation.

3. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

Correct answer: D

Rationale: When a nurse has developed a close relationship with a dying client's family, it is crucial to provide comprehensive support. Encouraging family discussion of feelings helps them express their emotions and concerns, fostering a sense of relief. Accepting the family's experience of anger without judgment validates their emotions and promotes trust. Facilitating the use of spiritual practices identified by the family acknowledges their beliefs and values, offering comfort and solace. Therefore, all of the above interventions are essential in providing holistic care and support during such a challenging time. Choices A, B, and C each play a vital role in addressing different aspects of the family's emotional and spiritual needs, making option D the correct answer.

4. A 31-year-old client is seeking contraceptive information. Before responding to the client’s questions about contraceptives, the nurse obtains a health history. What factor in the client’s history indicates to the nurse that oral contraceptives are contraindicated?

Correct answer: C

Rationale: The correct answer is C. Smoking, especially in clients over 30, increases the risk of thromboembolic events, making oral contraceptives contraindicated. Choice A (More than 30 years of age) is not a direct contraindication for oral contraceptives. Choice B (Had two multiple pregnancies) is not a factor that contraindicates the use of oral contraceptives. Choice D (Has a history of borderline hypertension) is not a specific contraindication for oral contraceptives unless it is severe or uncontrolled hypertension.

5. Which of the following drugs may cause weight gain?

Correct answer: B

Rationale: The correct answer is B, Steroids. Steroids are known to cause weight gain as a side effect. Amphetamines, choice A, are more likely to cause appetite suppression and weight loss. Antibiotics, choice C, and nonsteroidal anti-inflammatory drugs, choice D, are not typically associated with weight gain as a common side effect.

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