a nurse is planning care for a client who has a prescription for a bowel training program following a spinal cord injury which of the following action
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam

1. A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

Correct answer: D

Rationale: Administering a rectal suppository 30 minutes before scheduled defecation times is essential in a bowel-training program following a spinal cord injury. The suppository helps stimulate bowel movements and aids in establishing a regular bowel routine. Encouraging a maximum fluid intake of 1,500 ml per day (Choice A) might be beneficial for bowel function, but it is not specific to the bowel-training program. Increasing the intake of refined grains in the diet (Choice B) is not necessary and could potentially lead to constipation rather than improving bowel movements. Providing a cold drink prior to defecation (Choice C) may not directly contribute to the effectiveness of the bowel-training program compared to the use of a rectal suppository.

2. A patient is 1 day postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct action for a client 1 day postoperative following a total knee arthroplasty is to apply ice packs to the affected knee. Ice packs help reduce swelling and pain in such clients. Administering aspirin is contraindicated due to the risk of bleeding postoperatively. Keeping the affected leg in a dependent position can impair circulation and increase the risk of complications. Flexing the affected knee for extended periods can strain the surgical site and hinder the healing process.

3. A nurse is caring for a client who is 24 hours postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?

Correct answer: C

Rationale: Respecting cultural preferences promotes trust and client-centered care.

4. A nurse is teaching a client who has a new diagnosis of diabetes mellitus about managing blood glucose levels. Which of the following client statements indicates an understanding of the teaching?

Correct answer: C

Rationale: Taking insulin at the same time each day helps maintain stable blood glucose levels and prevent complications.

5. A nurse is reviewing the laboratory results of a client who has heart failure. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B: Hemoglobin 12 g/dL. In a client with heart failure, a decrease in hemoglobin levels can indicate anemia, which can exacerbate heart failure symptoms. Reporting this finding to the provider is crucial for appropriate management. Choice A, Potassium 4.0 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not typically require immediate reporting. Choice C, BUN 18 mg/dL, and Choice D, Sodium 137 mEq/L, are also within normal ranges and not directly related to heart failure management. Therefore, the hemoglobin level is the most critical finding to report in this scenario.

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