a charge nurse is recommending postpartum client discharge following a local disaster which of the following should the nurse recommend for discharge
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam

1. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?

Correct answer: D

Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.

2. A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: D

Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.

3. The correct method for determining the vastus lateralis site for I.M. injection is to:

Correct answer: D

Rationale: The vastus lateralis site is located in the middle third of the thigh.

4. After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client’s vital signs. What phase of the nursing process is being implemented by the nurse?

Correct answer: A

Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process. Choice B, 'Diagnosis,' would involve analyzing the collected data to identify the client's health problems. Choice C, 'Planning,' would be developing a plan of care based on the assessment findings. Choice D, 'Implementation,' is the phase where the nurse carries out the plan of care developed during the planning phase.

5. A client complains of difficulty swallowing when the nurse tries to administer capsule medication. Which of the following measures should the nurse take?

Correct answer: C

Rationale: When a client has difficulty swallowing capsule medication, the nurse should check the availability of a liquid preparation. This is a safer approach and ensures that the medication's integrity is maintained, providing an alternative form that is easier for the client to take. Dissolving the capsule in water (choice A) may alter the medication's effectiveness, breaking the capsule and mixing the contents with applesauce (choice B) is not recommended as it may cause an unpleasant taste, and crushing the capsule and placing it under the tongue (choice D) can be unsafe and affect the medication's absorption.

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