a nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery which of the followin a nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery which of the followin
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

Correct answer: C

Rationale: The priority action for the nurse is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or issues, the nurse can address them effectively, provide education or support, and encourage the client to comply with the necessary postoperative care. This approach fosters a patient-centered care environment. Demonstrating how to use the spirometer (Choice A) may be important but is not the priority at this moment. Setting a realistic postoperative goal (Choice B) is relevant but not as immediate as understanding the client's refusal. Requesting a respiratory therapist (Choice D) can be considered later if needed, but the nurse's initial focus should be on understanding the client's perspective.

2. Nurse Mike is providing care to a client with chronic myelogenous leukemia (CML). The nurse knows that the client is at risk for tumor lysis syndrome. Which of the following laboratory values requires immediate intervention?

Correct answer: A

Rationale: The correct answer is A: Increased uric acid level. In tumor lysis syndrome, rapid cell destruction releases large amounts of potassium, phosphate, and nucleic acids into the bloodstream. Uric acid can accumulate rapidly, leading to hyperuricemia, which can result in kidney damage due to urate crystal deposition. Immediate intervention is necessary to prevent renal complications. Choices B, C, and D are incorrect because while electrolyte imbalances are common in tumor lysis syndrome, hyperuricemia with potential kidney damage is the priority concern that requires immediate attention.

3. Maternal malnutrition at a critical period of development may have lifelong effects on an individual's pattern of genetic expression and on the tendency to develop obesity, which is a concept known as _____.

Correct answer: D

Rationale: Fetal programming refers to the concept that maternal nutrition during critical periods of development can have long-term effects on an individual's health and risk of diseases like obesity.

4. The nurse is planning care for a client with epilepsy. Which precautions does the nurse implement to ensure the safety of the client while in the hospital? (Select one that doesn't apply.)

Correct answer: Maintain the client on strict bed rest

Rationale: For a client with epilepsy, it is essential to avoid restraining them with strict bed rest as it can lead to complications like muscle atrophy, thrombosis, and pressure ulcers. Having suction equipment at the bedside is important in case of seizures to prevent aspiration. Keeping bed rails up can prevent falls during a seizure. Ensuring that the client has IV access is crucial for administering medications such as antiepileptic drugs or emergency medications if needed. Therefore, maintaining the client on strict bed rest is not a recommended precaution for a client with epilepsy.

5. An oncology patient will begin a course of chemotherapy and radiation therapy for the treatment of bone metastases. What is one means by which malignant disease processes transfer cells from one place to another?

Correct answer: D

Rationale: The correct answer is D: Invading healthy host tissues. Invasion is the process where malignant cells grow into surrounding healthy tissues, allowing the cancer to spread to other parts of the body. Choices A, B, and C are incorrect. Adhering to primary tumor cells does not involve the transfer of cells to other locations, inducing mutation of cells of another organ is not a mechanism of cell transfer, and phagocytizing healthy cells refers to the process of engulfing and digesting cells, which is not a method of cancer cell transfer.

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