a nurse is assessing a client for signs of allergic reaction which of the following should the nurse look for
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?

Correct answer: B

Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.

2. A client who is Rh-negative is being taught about Rh (D) immune globulin by a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: D

Rationale: Choice D is the correct answer because it reflects an understanding of Rh immune globulin administration. Rh immune globulin is given after delivery to prevent sensitization in future pregnancies, particularly if the baby is Rh-positive. Choice A is incorrect because Rh-negative partners do not affect the need for Rh immune globulin. Choice B is incorrect as Rh immune globulin is given if the baby is Rh-positive, not Rh-negative. Choice C is incorrect; there is no requirement to avoid immunizations after receiving Rh immune globulin.

3. A client is being taught about the use of levothyroxine. Which of the following should be included in the teaching?

Correct answer: B

Rationale: The correct answer is B: 'Take it at the same time every day.' It is important to take levothyroxine consistently at the same time each day to maintain stable thyroid hormone levels. Choice A is incorrect as levothyroxine should be taken on an empty stomach for better absorption. Choice C is incorrect because stopping levothyroxine suddenly can lead to adverse effects due to sudden changes in hormone levels. Choice D is also incorrect as hyperglycemia is not a common side effect associated with levothyroxine.

4. When teaching a client about the use of trazodone, what should be included?

Correct answer: A

Rationale: The correct answer is A. Trazodone can cause sedation, so clients should be cautioned about activities requiring alertness, like driving. Choice B is incorrect because trazodone is not a stimulant; it is actually a sedating antidepressant. Choice C is incorrect as all medications have potential side effects. Choice D is not specifically indicated for trazodone; the client should follow the prescribing healthcare provider's instructions regarding food intake.

5. A nurse is in an acute care facility, caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?

Correct answer: B

Rationale: The correct answer is B: 'Suppression of the urge to defecate.' Suppressing the urge to defecate can lead to constipation, especially in postoperative clients. It is essential to encourage clients to respond to the urge to defecate to prevent constipation. Increased fiber intake (Choice A) is beneficial for preventing constipation. Ambulation (Choice C) helps promote bowel motility and can reduce the risk of constipation. Daily laxative use (Choice D) may contribute to laxative dependence but is not the behavior most directly associated with increasing the risk of constipation in this scenario.

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