a nurse is implementing a plan of care for a client who has a wound infection which of the following actions should the nurse perform first a nurse is implementing a plan of care for a client who has a wound infection which of the following actions should the nurse perform first
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Nursing Elites

ATI RN

ATI Pharmacology Proctored Exam 2023 Quizlet

1. When caring for a client with a wound infection, which action should the nurse perform first in the plan of care?

Correct answer: B

Rationale: The priority action when caring for a client with a wound infection is to obtain a wound specimen for culture before initiating antibiotic therapy. This step is crucial to identify the specific microorganism causing the infection, allowing for targeted antibiotic treatment. Reviewing WBC laboratory findings and applying a wound dressing are important steps, but obtaining a wound specimen for culture takes precedence as it guides appropriate antibiotic therapy by identifying the causative organism.

2. A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position?

Correct answer: D

Rationale: Placing the client in a high Fowler’s position helps prevent aspiration and promotes proper digestion and feeding tube function.

3. A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Correct answer: B

Rationale: The correct answer is B: 'Distended neck veins.' Distended neck veins are a sign of fluid volume excess, indicating an overload of fluids in the body. This can be caused by excessive fluid administration. Hypotension (choice A) is more commonly associated with fluid volume deficit. Slow capillary refill (choice C) and a weak, thready pulse (choice D) are also signs of decreased fluid volume, not fluid volume excess.

4. Why does the nurse have a 2-year-old boy sit in a “tailor” position while palpating for the presence of the testes?

Correct answer: A

Rationale: The tailor position stretches the muscle responsible for the cremasteric reflex, preventing it from contracting and pulling the testes into the pelvic cavity. This position helps accurately palpate the testes. Choice B is incorrect because the position does not facilitate the palpation of undescended testes specifically. Choice C is incorrect as it does not relate to the rationale behind the tailor position. Choice D is incorrect as the reason for using the tailor position is not related to the child's need for privacy.

5. A nurse is reviewing the laboratory results of a client who is receiving warfarin therapy for atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

Correct answer: A

Rationale: The correct answer is A. An INR of 1.8 is below the therapeutic range for a client receiving warfarin, indicating a potential risk of blood clots. This value should be reported to the provider for further evaluation and possible adjustment of the warfarin dosage. Choices B, C, and D are within normal ranges and do not directly relate to the effectiveness or safety of warfarin therapy in this scenario, making them less urgent to report.

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