a nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy which of the following actions should the nurse take a nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. A nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.

2. Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is option B: Call the practitioner, report the client’s symptoms, and obtain further orders. The client is displaying symptoms that indicate potential complications, such as internal bleeding, which require immediate medical evaluation. Option A is incorrect because the client's condition suggests a more urgent need for assessment. Option C is inappropriate as it does not address the seriousness of the client's symptoms. Option D is dangerous and could exacerbate any underlying issue the client may be experiencing.

3. Which action demonstrates health advocacy?

Correct answer: B

Rationale: Health advocacy involves advocating for policies that positively impact health care access for all individuals. By working to change policies, a person promotes equitable access to necessary care and resources, which aligns with the principles of health advocacy.

4. A client with chronic Neutropenia is receiving Filgrastim. What action should the nurse take to assess for an adverse effect of filgrastim?

Correct answer: A

Rationale: Bone pain is a known adverse effect of Filgrastim, which is dose-related. By assessing for bone pain, the nurse can monitor for this common side effect. Acetaminophen and, if necessary, an opioid analgesic can be used to manage the bone pain associated with Filgrastim. Assessing for right lower quadrant pain, crackles in the bases of the lungs, or heart murmurs would not directly relate to the adverse effects of Filgrastim in a client with chronic Neutropenia.

5. 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.

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