a nurse is assessing a client who is postoperative following a hip arthroplasty which of the following findings is the priority for the nurse to repor
Logo

Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings is the priority for the nurse to report?

Correct answer: C

Rationale: The correct answer is C, warmth and redness in the calf. These symptoms may indicate a deep vein thrombosis (DVT), a serious complication following hip arthroplasty that requires immediate attention. A heart rate of 90/min and blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client and do not indicate an urgent issue. Pink-tinged urine may suggest blood in the urine, which should be monitored but is not as critical as the potential DVT.

2. A client is receiving brachytherapy for the treatment of prostate cancer. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action the nurse should take when caring for a client receiving brachytherapy is to limit the client's visitors to 30 minutes per day. This is crucial to reduce exposure to radiation and maintain safety during the brachytherapy procedure. Cleansing equipment before removal from the client's room may be important for infection control but is not directly related to brachytherapy procedures. Discarding the client's linens in a double bag and discarding the radioactive source in a biohazard bag are incorrect choices as they do not specifically address the safety measures needed during brachytherapy for prostate cancer.

3. A client with a new diagnosis of diabetes mellitus is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Trim your toenails straight across to prevent injury.' In clients with diabetes, trimming toenails straight across is essential to prevent ingrown toenails and injury. Choice A is incorrect because soaking feet in warm water can lead to dryness, which is not recommended for diabetic foot care. Choice C is incorrect as applying lotion between the toes can create excess moisture, increasing the risk of fungal infections. Choice D is incorrect because although cotton socks are recommended, the primary purpose is to prevent moisture buildup, not specifically to keep the feet dry.

4. How should a healthcare provider care for a patient with a tracheostomy?

Correct answer: C

Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.

5. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?

Correct answer: A

Rationale: The correct intervention for a client with obsessive-compulsive disorder is to allow the client enough time to perform rituals. This helps manage anxiety and stress in individuals with OCD. Allowing time for rituals can provide a sense of control and reduce distress. Choice B, giving the client autonomy in scheduling activities, may not address the core symptoms of OCD related to rituals and compulsions. Choice C, discouraging the client from exploring irrational fears, goes against the principles of exposure therapy, which is a common treatment for OCD. Choice D, providing negative reinforcement for ritualistic behaviors, is not recommended as it can reinforce the behavior rather than help the client manage it.

Similar Questions

A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle changes to manage the condition. Which of the following instructions should the nurse include?
A nurse is assessing a client who has a history of angina and reports chest pain. Which of the following actions should the nurse take first?
How should a healthcare professional administer a subcutaneous injection?
A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?
A nurse is providing care for a client who is in the advanced stage of amyotrophic lateral sclerosis (ALS). Which of the following referrals is the nurse's priority?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses