a nurse is planning care for a client who is postoperative following a laminectomy which of the following interventions should the nurse include in th

ATI RN

ATI Exit Exam RN

1. A nurse is planning care for a client who is postoperative following a laminectomy. Which of the following interventions should the nurse include in the plan of care?

A. Elevate the client's legs while in bed.
B. Reposition the client every 2 hours.
C. Maintain bed rest for the first 24 hours postoperatively.
D. Ambulate the client on the first postoperative day.

Correct answer: D

Rationale: Ambulating the client on the first postoperative day is crucial to prevent complications like deep vein thrombosis and aid in the recovery process. Elevating the legs while in bed can help with circulation but is not as effective in preventing complications related to immobility post-surgery. Repositioning every 2 hours is important for preventing pressure ulcers but does not directly address postoperative care. Maintaining bed rest for the first 24 hours postoperatively can increase the risk of complications associated with immobility, making early ambulation a more appropriate intervention.

2. A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?

A. Decreased level of consciousness
B. Inability to identify common objects
C. Poor problem-solving ability
D. Preoccupation with somatic disturbances

Correct answer: B

Rationale: In schizophrenia, clients often display an inability to identify common objects due to cognitive impairment. This is known as associative agnosia, where individuals struggle to recognize familiar objects, faces, or sounds. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head trauma or drug overdose. Poor problem-solving ability may be seen in various mental health disorders but is not specific to schizophrenia. Preoccupation with somatic disturbances is more commonly seen in somatic symptom disorders or somatic delusions, not a typical finding in schizophrenia.

3. A healthcare professional is preparing to administer a blood transfusion to a client. Which of the following actions should the healthcare professional take first?

A. Obtain the client's vital signs.
B. Ensure the client's IV access is patent.
C. Prime the IV tubing with 0.9% sodium chloride.
D. Verify the client's identity.

Correct answer: D

Rationale: Verifying the client's identity is the first crucial action the healthcare professional should take before administering a blood transfusion. This step ensures that the right blood is given to the right client, helping prevent errors. Obtaining vital signs, ensuring IV access, and priming IV tubing are important steps in the process but verifying the client's identity takes precedence for patient safety and accurate care delivery.

4. Which lab value should be monitored in patients receiving furosemide?

A. Monitor potassium levels
B. Monitor sodium levels
C. Monitor calcium levels
D. Monitor glucose levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in patients receiving furosemide. Furosemide is a loop diuretic that can lead to potassium loss in the urine, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications associated with low potassium levels, such as cardiac arrhythmias. Monitoring sodium levels (choice B) is not typically necessary with furosemide use, as it primarily affects potassium levels. Calcium levels (choice C) and glucose levels (choice D) are not directly impacted by furosemide and require monitoring for other conditions or medications.

5. What is the best way to manage a patient's pain postoperatively?

A. Administer analgesics regularly
B. Administer pain medication PRN
C. Encourage deep breathing exercises
D. Provide distraction techniques

Correct answer: A

Rationale: The correct answer is A: Administer analgesics regularly. Postoperative pain management often requires a scheduled, around-the-clock administration of analgesics to maintain a consistent level of pain relief and minimize the risk of breakthrough pain. Choice B, administering pain medication PRN (as needed), may lead to inadequate pain control as the medication is not given preemptively. Choice C, encouraging deep breathing exercises, can be beneficial for pain management but should be used as an adjunct to analgesic therapy. Choice D, providing distraction techniques, may help some patients cope with pain but should not be the primary method of pain management postoperatively.