a nurse is caring for a client who is postoperative following a total knee arthroplasty which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Exit Exam 2023 Quizlet

1. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Keeping the client's legs elevated is the appropriate action to prevent venous thromboembolism following a total knee arthroplasty. Elevating the legs helps promote circulation and reduce the risk of blood clots. Placing a pillow under the client's knees may provide comfort but does not address the specific postoperative complication. Flexing the client's knee every 2 hours may be contraindicated as excessive movement can disrupt the surgical site. Applying heat to the operative knee is not recommended immediately postoperatively as it can increase swelling and discomfort.

2. What is the best intervention for a patient with respiratory distress?

Correct answer: A

Rationale: The correct answer is to administer oxygen. In respiratory distress, the priority intervention is to improve oxygenation. Administering oxygen helps increase the oxygen levels in the blood, supporting respiratory function. While bronchodilators may be used in specific respiratory conditions like asthma or COPD, they are not the primary intervention for respiratory distress. IV fluids are not indicated as the initial treatment for respiratory distress unless there is an underlying cause such as dehydration. Corticosteroids may be used in certain respiratory conditions to reduce inflammation, but they are not the first-line intervention for acute respiratory distress.

3. What is the initial action a healthcare provider should take when a patient presents with chest pain?

Correct answer: C

Rationale: The correct initial action when a patient presents with chest pain is to obtain an ECG. This helps assess the heart's electrical activity and determine the cause of chest pain. Administering aspirin or oxygen therapy may be necessary later based on the ECG findings, but obtaining an ECG is the priority to evaluate the cardiac status. Surgery preparation is not the initial action for chest pain and should only be considered after a thorough assessment.

4. A client receiving radiation therapy for breast cancer may experience which of the following side effects that the nurse should monitor for?

Correct answer: C

Rationale: During radiation therapy for breast cancer, one common side effect is skin irritation due to the impact of radiation on the skin cells. This side effect should be closely monitored by the nurse. Fatigue may also occur as a side effect of radiation therapy, but skin irritation is more specific to the treatment area and is a priority in this case. Nausea and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices.

5. Which electrolyte imbalance is commonly seen in patients taking furosemide?

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, can lead to potassium loss in the urine, resulting in hypokalemia. This electrolyte imbalance is commonly seen in patients taking furosemide and requires close monitoring. Choices B, C, and D are incorrect because furosemide does not typically cause hyponatremia, hyperkalemia, or hypercalcemia as frequently as it causes hypokalemia.

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