the nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy which intervention should the nurse implem

ATI RN

ATI RN Custom Exams Set 1

1. The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

A. Establish a rapport with the client to decrease embarrassment during site assessment
B. Encourage the client to lie in the lithotomy position twice a day
C. Milk the tube inserted during surgery to facilitate the passage of flatus
D. Digitally dilate the rectal sphincter to express old blood

Correct answer: A

Rationale: Establishing rapport with the client is crucial in postoperative care to create a trusting relationship, reduce embarrassment, and enhance comfort during assessments. Encouraging the client to lie in the lithotomy position is not recommended after a hemorrhoidectomy as it can be uncomfortable and may disrupt wound healing. Milking the tube inserted during surgery is not a standard practice and could lead to complications. Digitally dilating the rectal sphincter is not indicated post-hemorrhoidectomy and can cause harm to the client.

2. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

A. Provide nutrients
B. Increase protein stores
C. Elevate the circulating blood volume
D. Divert blood flow away from the liver temporarily

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Salt-poor albumin is given to increase the circulating blood volume, which helps reduce ascites by improving fluid distribution within the body. Choices A, B, and D are incorrect because salt-poor albumin is not administered to provide nutrients, increase protein stores, or divert blood flow away from the liver.

3. When assessing the integumentary system of a client with anorexia nervosa, which finding would support the diagnosis?

A. Preoccupation with calories
B. Thick body hair
C. Sore tongue
D. Dry, brittle hair

Correct answer: D

Rationale: Dry, brittle hair is a common sign of malnutrition, often seen in clients with anorexia nervosa. In anorexia nervosa, the body lacks essential nutrients due to severe calorie restriction, leading to dryness and brittleness of the hair. Choices A, B, and C are less likely to directly indicate anorexia nervosa. Preoccupation with calories can be a behavioral symptom, thick body hair is not a typical finding associated with anorexia nervosa, and a sore tongue is more commonly related to nutritional deficiencies like vitamin deficiencies rather than anorexia nervosa.

4. Which situation(s) are classified as natural disasters?

A. Blizzards
B. Blizzards, Volcanic eruptions
C. Volcanic eruptions
D. Structural collapse

Correct answer: B

Rationale: Blizzards and volcanic eruptions are classified as natural disasters because they are caused by natural forces beyond human control. In contrast, structural collapses are typically a result of man-made factors, making them not classified as natural disasters. Therefore, the correct answer is B.

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

A. Rice
B. Rye
C. Wheat
D. Barley

Correct answer: A

Rationale: The correct answer is A, Rice. Rice is a gluten-free grain and is safe for individuals with celiac disease. Rye, wheat, and barley contain gluten, which can trigger adverse reactions in individuals with celiac disease. Therefore, choices B, C, and D are incorrect for someone with this condition.