a nurse is caring for a client who is being discharged home following a cerebrovascular accident which of the following documents should the nurse pla
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023 with NGN

1. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?

Correct answer: B

Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.

2. Which of the following actions should the nurse take to ensure the safety of a client using home oxygen?

Correct answer: B

Rationale: The correct answer is B: 'Keep oxygen tanks upright at all times.' Oxygen tanks should be stored in an upright position to prevent leaks and accidents. Choice A is incorrect as smoking should never be allowed near oxygen due to the risk of fire. Choice C is incorrect as oxygen equipment should be stored in a well-ventilated area, not in a closet. Choice D is incorrect as oxygen tanks must be kept a minimum of 5 to 10 feet away from heat sources to prevent combustion. Therefore, the best practice is to keep oxygen tanks upright to ensure safety.

3. A client is concerned about extreme fatigue after an acute myocardial infarction. What is the best strategy the nurse can suggest to promote independence in self-care?

Correct answer: B

Rationale: The best strategy to promote independence in self-care for a client concerned about extreme fatigue after an acute myocardial infarction is to instruct the client to gradually resume self-care tasks, with rest periods. This approach allows the client to regain independence without overexerting. Choice A is incorrect because encouraging the client to rest completely and letting the healthcare team take over self-care tasks may hinder independence. Choice C is incorrect as assigning assistive personnel to complete self-care tasks does not promote the client's independence. Choice D is not the best option as the primary focus should be on empowering the client to perform self-care tasks independently.

4. A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take after administering an influenza virus immunization by the intradermal route is to avoid massaging the site. Massaging the site can spread the vaccine, potentially reducing its effectiveness. Rubbing the site in a circular motion or applying a bandage are not recommended actions as they can also interfere with the proper absorption of the vaccine.

5. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?

Correct answer: C

Rationale: The correct answer is C: Serum potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Therefore, the nurse should monitor the client's serum potassium levels to prevent hyperkalemia, which can be a potential side effect of spironolactone. Monitoring total bilirubin levels (A) is not specifically required for clients taking spironolactone. Urine ketones (B) are not directly influenced by spironolactone use. Platelet count (D) is not typically monitored in clients taking spironolactone.

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