a nurse is caring for a client who has raynauds disease which of the following actions should the nurse take

ATI RN

ATI Exit Exam 180 Questions Quizlet

1. A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

A. Provide information about stress management.
B. Maintain a warm temperature in the client's room.
C. Administer epinephrine for acute episodes.
D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: Corrected Rationale: Providing information about stress management is essential when caring for a client with Raynaud's disease because stress can trigger episodes. Stress management techniques can help the client avoid triggers and reduce the frequency of episodes. Choice B is incorrect because maintaining a warm temperature, rather than a cool one, helps prevent vasoconstriction and can be beneficial for clients with Raynaud's disease. Choice C is incorrect because epinephrine is not a standard treatment for Raynaud's disease; it is more commonly used for severe allergic reactions. Choice D is incorrect because glucocorticoid steroids are not typically used in the management of Raynaud's disease.

2. What is the best method to assess pain in a non-verbal patient?

A. Observe for facial expressions
B. Observe for restlessness
C. Observe for sweating
D. Check for non-verbal cues

Correct answer: A

Rationale: The correct answer is to observe for facial expressions when assessing pain in a non-verbal patient. Facial expressions can provide vital clues about the patient's pain level and discomfort. Choices B and C, observing for restlessness and sweating, can be less specific and may indicate other issues besides pain. Choice D, checking for non-verbal cues, is too broad and does not specify the crucial aspect of focusing on facial expressions.

3. During a change-of-shift report, a nurse is receiving information about an adult female client who is postoperative. Which of the following client information should the nurse report?

A. The client's oxygen saturation is 95%
B. The client's blood pressure is 110/70 mm Hg
C. The client has a temperature of 36.8°C (98.2°F)
D. The client's heart rate is 88/min

Correct answer: B

Rationale: The correct answer is B because a blood pressure of 110/70 mm Hg is within the normal range and stable. Reporting this information is crucial to monitor the client's condition postoperatively. Oxygen saturation of 95% is acceptable, a temperature of 36.8°C (98.2°F) is normal, and a heart rate of 88/min is within the expected range for an adult female client, so these values do not raise concerns that require immediate reporting.

4. A nurse is teaching a client who has a new diagnosis of diabetes mellitus about managing blood glucose levels. Which of the following client statements indicates an understanding of the teaching?

A. "I will monitor my blood pressure regularly."
B. "I will keep my blood glucose level between 200 and 250 mg/dL."
C. "I will take my insulin at the same time each day."
D. "I will eat three large meals each day."

Correct answer: C

Rationale: Taking insulin at the same time each day helps maintain stable blood glucose levels and prevent complications.

5. How should a healthcare professional administer a subcutaneous injection?

A. Insert the needle at a 45-degree angle
B. Insert the needle at a 90-degree angle
C. Use a Z-track method
D. Insert the needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering subcutaneous injections is to insert the needle at a 45-degree angle. This angle ensures that the medication is delivered into the subcutaneous tissue, which is located just below the skin. Inserting the needle at a 90-degree angle is more appropriate for intramuscular injections, while using a Z-track method is specific to intramuscular injections to prevent leakage of medication into the subcutaneous tissue. Inserting the needle at a 15-degree angle would not reach the subcutaneous tissue effectively.