a nurse is assessing a client who has a long arm cast which of the following findings indicates a moderate complication when assessing for acute compa
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A healthcare provider is assessing a client who has a long arm cast. Which of the following findings indicates a moderate complication when assessing for acute compartment syndrome?

Correct answer: D

Rationale: Edema is a common sign of acute compartment syndrome, which is a medical emergency caused by increased pressure within a muscle compartment, requiring immediate intervention. Shortness of breath (Choice A) is more indicative of a respiratory issue rather than acute compartment syndrome. Petechiae (Choice B) are pinpoint, round spots that appear on the skin due to bleeding under the skin and are not typically associated with acute compartment syndrome. Change in mental status (Choice C) is more suggestive of neurological issues rather than acute compartment syndrome.

2. A nurse is caring for a client with chronic pain. Which of the following interventions should the nurse prioritize?

Correct answer: A

Rationale: Administering pain medications as prescribed is a priority to manage chronic pain effectively. Pain medications help alleviate the client's discomfort and improve their quality of life. Encouraging physical activity, monitoring for depression, and educating about alternative therapies are important interventions but may not directly address the immediate need for pain relief in a client with chronic pain. Physical activity and alternative therapies can be beneficial as part of a holistic pain management plan, but addressing the pain directly should be the initial priority.

3. A nurse is caring for a client who has a nasogastric (NG) tube and is receiving enteral feedings. The client reports feeling nauseated. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The correct action for the nurse to take first when a client with a nasogastric tube reports feeling nauseated is to check the client's bowel sounds. This assessment helps the nurse evaluate for possible complications, such as a blockage or decreased gastric motility, that could be causing the nausea. Administering an antiemetic (Choice A) should not be the first action without assessing the underlying cause of the nausea. Slowing the rate of the feeding (Choice C) may be appropriate but is not the priority until further assessment is done. Placing the client in a supine position (Choice D) is not typically indicated for managing nausea in this situation.

4. A nurse is preparing to administer a dose of ampicillin. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct answer is to 'Check for penicillin allergy.' Before administering ampicillin, it is crucial to assess the patient for any history of penicillin allergy. This is essential to prevent an adverse allergic reaction, as ampicillin belongs to the penicillin class of antibiotics. Administering ampicillin with food (Choice A) is not a standard requirement and does not impact its effectiveness. Monitoring liver function (Choice C) is not directly related to the immediate pre-administration assessment for ampicillin. Administering ampicillin intramuscularly (Choice D) is not typically the route of administration for this antibiotic, as it is usually given intravenously or orally.

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

Correct answer: B

Rationale: Urge suppression can lead to constipation by delaying bowel movements and causing fecal impaction, especially in postoperative patients. Regular fluid intake (choice A) is important to prevent constipation by maintaining hydration and aiding in bowel movements. Increased physical activity (choice C) helps stimulate bowel function and prevent constipation. Adequate dietary fiber (choice D) is essential for promoting healthy bowel movements and preventing constipation. However, urge suppression (choice B) is the behavior that directly contributes to constipation in this scenario.

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