which intervention would be the most important for the nurse to implement for the client with a left nephrectomy
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 2

1. What intervention would be the most important for the nurse to implement for the client with a left nephrectomy?

Correct answer: A

Rationale: The most important intervention for a client with a left nephrectomy is to assess the intravenous fluids for rate and volume. After nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Changing the surgical dressing daily, monitoring medication levels, and tracking meal intake are also important aspects of care but not as critical as ensuring adequate intravenous fluid management post-surgery.

2. The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?

Correct answer: A

Rationale: The correct answer is A: Second intercostal space, right sternal border. The aortic valve is best auscultated at the second intercostal space, right sternal border, where the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as they are not the recommended anatomical positions for auscultating the murmur of aortic stenosis.

3. Infection or inflammation of small sacs that protrude from the lumen of the colon is known as:

Correct answer: B

Rationale: Diverticulitis refers to the infection or inflammation of diverticula in the colon. Choice A, Diverticulosis, is the condition of having diverticula without inflammation. Choices C and D, Cholelithiasis and Cholecystitis, are related to the gallbladder and not the colon, making them incorrect in this context.

4. The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion?

Correct answer: A

Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is the correct precaution to implement when the cross-match reveals the presence of antibodies that cannot be cross-matched. This allows the nurse to monitor for any adverse reactions due to the presence of antibodies. Re-crossmatching the blood until the antibodies are identified is not practical and may delay the transfusion, potentially compromising the patient's condition. Having the client sign a permit to receive uncrossmatched blood is not the best course of action as the focus should be on ensuring a safe transfusion. Having an unlicensed nursing assistant stay with the client does not address the specific precaution needed to manage a transfusion in the presence of antibodies.

5. Which of the following statements does NOT apply to a nursing plan of care?

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.

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