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. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial to ensure adequate pain control in the immediate postoperative period. Choice A is incorrect because clear liquids are typically initiated gradually and advanced as tolerated but not specifically at 6 hours post-surgery. Choice B is incorrect as cromolyn nebulizer solution is not indicated for postoperative pain management in this scenario. Choice C is incorrect as applying a warm compress may not be appropriate for the operative site after appendicitis surgery and can potentially increase the risk of infection.

3. A client receiving chemotherapy has developed stomatitis. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with stomatitis due to chemotherapy is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the already inflamed and sore oral mucosa. Providing lemon-glycerin swabs may further irritate the mucosa due to the acidic nature of lemon. Avoiding toothpaste is advisable as many toothpaste products contain ingredients that can aggravate stomatitis. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol-based mouthwashes can be too harsh and drying for the already sensitive oral tissues.

4. A client has hypoglycemia and is conscious. Which of the following actions should the nurse take?

Correct answer: B

Rationale: In conscious clients with hypoglycemia, the most appropriate action is to provide a rapidly absorbed carbohydrate source like fruit juice to raise blood glucose levels quickly. Administering glucagon intramuscularly (IM) is usually reserved for unconscious clients or those who are unable to take oral glucose. Providing peanut butter or water would not rapidly address the hypoglycemic state as fruit juice would.

5. A healthcare professional is planning care for a client who has a prescription for mechanical restraints. Which of the following interventions should the healthcare professional include in the plan?

Correct answer: B

Rationale: When a client has a prescription for mechanical restraints, it is essential to provide continuous monitoring for their safety and to observe any behavioral changes. Having a staff member stay with the client continuously allows for immediate intervention if needed. Documenting the client's status every 60 minutes (Choice A) may not provide real-time monitoring, which is crucial in this situation. While measuring vital signs every 4 hours (Choice C) is important, continuous observation takes precedence in this scenario. Obtaining a prescription for the restraints every 8 hours (Choice D) is not a necessary intervention once the initial prescription is in place.

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