a nurse is caring for a client who is postoperative following a colon resection and reports pain which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A client who is postoperative following a colon resection reports pain. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Administering a PRN dose of morphine is the most appropriate action to manage postoperative pain in a client following a colon resection. Morphine is a potent analgesic commonly used to relieve moderate to severe pain, especially in postoperative settings. While assisting the client to change positions in bed, encouraging relaxation techniques, and offering a back massage can provide comfort and support, they may not be sufficient in managing the pain following a major surgical procedure like a colon resection. Therefore, the priority intervention for acute postoperative pain control in this scenario is to administer medication like morphine.

2. A client has a new prescription for furosemide. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct instruction for a client taking furosemide is to take the medication with meals. This helps prevent gastrointestinal upset and improves medication tolerance. Option A is incorrect because furosemide is a loop diuretic that can cause potassium depletion, so avoiding foods high in potassium is not necessary. Option B is incorrect as furosemide typically lowers blood pressure. Option C is incorrect because furosemide is a diuretic that promotes fluid loss rather than retention.

3. A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD) who is prescribed home oxygen. Which of the following statements should the nurse make?

Correct answer: A

Rationale: The correct statement for the nurse to make is to advise the client to check the oxygen equipment daily for proper function. This is crucial to ensure the client's home oxygen therapy is working effectively and safely. Choice B is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored upright, not lying flat. Choice D is incorrect and unsafe advice, as smoking near an oxygen source can lead to a fire hazard.

4. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which manifestation should the nurse expect?

Correct answer: B

Rationale: Jitteriness is a common symptom of neonatal hypoglycemia. When a newborn has a low blood glucose level, they may exhibit signs of central nervous system dysfunction, such as jitteriness. Loose stools (Choice A) are not typically associated with neonatal hypoglycemia. Hypertonia (Choice C) refers to increased muscle tone, which is not a common manifestation of hypoglycemia in newborns. Abdominal distention (Choice D) is more often associated with gastrointestinal issues rather than hypoglycemia.

5. Which lab value is most critical to monitor in a patient receiving insulin therapy?

Correct answer: A

Rationale: The correct answer is to monitor blood glucose levels. When a patient is receiving insulin therapy, it is crucial to monitor blood glucose levels regularly to prevent hypoglycemia, a potential side effect of insulin therapy. Monitoring potassium, calcium, or sodium levels is important for different medical conditions or treatments and is not directly related to insulin therapy.

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