the unlicensed nursing assistant is applying elastic compression stockings to the client which action by the assistant warrants immediate interventio
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 5

1. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

Correct answer: A

Rationale: The correct answer is A because compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is not a cause for immediate intervention as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C demonstrates the correct technique of elevating the feet while lying down to put on the stockings. Choice D also shows good care by making sure the toes were warm after putting the stockings on.

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

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.

3. Which vitamin deficiency is commonly associated with prolonged antibiotic use?

Correct answer: D

Rationale: The correct answer is Vitamin K. Prolonged antibiotic use can disrupt the gut flora, which is responsible for synthesizing Vitamin K. This disruption can lead to a Vitamin K deficiency and an increased risk of bleeding. Vitamin A, B6, and C deficiencies are not typically associated with prolonged antibiotic use.

4. Which electrolyte imbalance is a potential side effect of diuretics?

Correct answer: D

Rationale: The correct answer is D, Hypokalemia. Diuretics commonly lead to hypokalemia, which is low potassium levels in the body. Hyperkalemia (choice A) is the opposite, indicating high potassium levels. Hypercalcemia (choice B) refers to elevated calcium levels, not typically associated with diuretics. Hypomagnesemia (choice C) is low magnesium levels and can also be a consequence of diuretic use, but potassium imbalance is more common.

5. The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching?

Correct answer: A

Rationale: The correct answer is A. Lying flat in the supine position for 12 hours after a renal biopsy is essential to prevent bleeding and promote recovery. This position helps apply pressure to the biopsy site, reducing the risk of bleeding. Choices B, C, and D are incorrect because continuing oral fluids restriction, changing the dressing, and activating the patient-controlled analgesia pump do not directly indicate compliance with the crucial post-biopsy teaching of maintaining the supine position.

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