a nurse is planning care for a client who has cirrhosis which of the following interventions should the nurse include
Logo

Nursing Elites

ATI RN

ATI Exit Exam RN

1. A nurse is planning care for a client who has cirrhosis. Which of the following interventions should the nurse include?

Correct answer: B

Rationale: The correct answer is to measure the client's abdominal girth daily. Measuring abdominal girth helps monitor for ascites, a common complication of cirrhosis. Limiting sodium intake is important in cirrhosis but there is no specific value given, making choice A less precise. Monitoring urine specific gravity is not directly related to cirrhosis management, making choice C incorrect. Encouraging the client to drink 3 liters of fluid per day may not be suitable for all patients with cirrhosis, especially those with fluid restrictions, so choice D is not the most appropriate intervention.

2. What is the priority intervention for a patient with a suspected pulmonary embolism?

Correct answer: A

Rationale: The correct answer is A: Administer oxygen. Administering oxygen is the priority intervention for a patient with a suspected pulmonary embolism to improve oxygenation levels. In pulmonary embolism, there is a blockage in one of the pulmonary arteries, leading to decreased oxygen exchange. Administering oxygen helps increase oxygen saturation levels. Anticoagulants (Choice B) are essential in the treatment of pulmonary embolism but are not the initial priority intervention. Surgery (Choice C) is not typically the first-line treatment for pulmonary embolism. Monitoring oxygen saturation (Choice D) is important but administering oxygen takes precedence as the immediate action to address hypoxemia.

3. A nurse is planning care for a client who is receiving hemodialysis. What action should the nurse include in the plan?

Correct answer: C

Rationale: The correct action that the nurse should include in the plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is important to prevent complications such as infection or excessive bleeding. Withholding all medications until after dialysis (Choice A) is not necessary unless specific medications need to be avoided due to the dialysis process. Rehydrating with dextrose 5% in water for orthostatic hypotension (Choice B) is not directly related to post-dialysis care. Giving an antibiotic 30 minutes before dialysis (Choice D) is not a standard practice unless there is a specific clinical indication.

4. A nurse is reviewing the medical record of a client who is receiving gentamicin for a wound infection. Which of the following findings should the nurse report to the provider?

Correct answer: A

Rationale: An elevated BUN level indicates possible nephrotoxicity, which is a side effect of gentamicin and should be reported. Elevated serum creatinine and WBC count are not specifically related to gentamicin therapy. Normal serum glucose levels are also within the expected range.

5. A client at 14 weeks gestation reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?

Correct answer: A

Rationale: The correct response is to use open-ended questions that allow the client to explore and express their feelings. Choice A encourages the client to describe their feelings, fostering open communication and providing an opportunity for the client to express themselves freely. Choices B and C do not directly address the client's feelings and may not promote open communication. Choice D focuses on the timing of the feelings rather than exploring the feelings themselves, making it a less therapeutic response.

Similar Questions

Which of the following lab values should the nurse monitor for a patient receiving heparin therapy?
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings should the nurse report to the provider?
A client who is 2 hours postoperative following a kidney biopsy is being assessed by a nurse. Which of the following findings should the nurse report to the provider?
A nurse is providing teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?
What is the first intervention for a patient experiencing anaphylactic shock?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses