a nurse is caring for a client who is postoperative when the nurse prepares to change the clients dressing they say every time you change my bandage i a nurse is caring for a client who is postoperative when the nurse prepares to change the clients dressing they say every time you change my bandage i
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Nursing Elites

ATI RN

ATI Leadership Practice A

1. A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, 'Every time you change my bandage, it hurts so much.' Which of the following interventions is the nurse's priority action?

Correct answer: C

Rationale: The correct answer is to administer pain medication 45 minutes before changing the client's dressing. This intervention is the priority action because the client is experiencing pain during the dressing change. Providing pain relief beforehand can help minimize the discomfort and improve the overall experience for the client. Encouraging relaxation techniques (choice A) or educating about dressing change importance (choice B) are valuable but addressing pain is the priority. Assisting the client to a comfortable position (choice D) is essential for the procedure but does not directly address the client's pain.

2. A client has a new prescription for Oxycodone/Acetaminophen. Which of the following instructions should be included in the discharge teaching?

Correct answer: B

Rationale: The correct answer is to instruct the client to avoid taking additional Acetaminophen while on Oxycodone/Acetaminophen. This is important to prevent exceeding the maximum recommended dose and reducing the risk of liver toxicity. Oxycodone/Acetaminophen already contains Acetaminophen, so additional intake can lead to an overdose of this component. Choices A, C, and D are incorrect. Taking the medication on an empty stomach or increasing fiber intake are not specific instructions related to this medication. Avoiding taking the medication before bedtime is not directly relevant to the combination of Oxycodone/Acetaminophen.

3. Is the parietal pericardium attached to the surface of the heart?

Correct answer: True

Rationale: The parietal pericardium is a tough, fibrous outer layer that is attached to the diaphragm and the sternum but not directly to the surface of the heart. It forms a sac around the heart known as the pericardial sac. Therefore, the statement that the parietal pericardium is attached to the surface of the heart is false.

4. Which nutrient deficiency produces microcytic anemia, fatigue, faulty digestion, blue sclerae, pale conjunctivae, and tachycardia?

Correct answer: B

Rationale: A deficiency in iron can lead to various symptoms, such as microcytic anemia, fatigue, faulty digestion, blue sclerae, pale conjunctivae, and tachycardia. Iron-deficiency anemia may be caused by inadequate dietary intake; accelerated demand or losses; and inadequate absorption secondary to diarrhea, decreased acid secretions, or antacid therapy. Iron deficiency is frequently the result of postnatal feeding practices and has a serious impact on growth and mental and psychomotor development in infants and children. Choices A, C, and D are incorrect as zinc deficiency typically presents with symptoms like impaired wound healing, taste abnormalities, and hair loss; sodium deficiency can lead to symptoms such as muscle cramps, dizziness, and confusion; and potassium deficiency may cause muscle weakness, fatigue, and abnormal heart rhythms.

5. What is a severe allergic reaction that can cause difficulty breathing and shock?

Correct answer: A

Rationale: Anaphylaxis is the correct answer. It is a severe, potentially life-threatening allergic reaction that can lead to difficulty breathing, low blood pressure, and loss of consciousness. An asthma attack is a separate condition characterized by narrowed airways and difficulty breathing, but it is not necessarily related to an allergic reaction like anaphylaxis. Bronchospasm refers to the sudden constriction of muscles in the bronchi, leading to breathing difficulties, and is not specific to allergic reactions. Hypersensitivity is a general term for an exaggerated immune response to a substance, which may or may not manifest as severe allergic reactions like anaphylaxis.

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