a nurse is preparing a client for a surgical procedure the client refuses to remove religious jewelry what is the best course of action
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. A client is preparing for a surgical procedure but refuses to remove religious jewelry. What is the best course of action?

Correct answer: B

Rationale: The best course of action is to ask the client for permission to secure the jewelry. This respects the client's religious beliefs while also ensuring that the jewelry does not interfere during the surgical procedure. Proceeding with surgery without addressing the presence of the jewelry can lead to complications or distress for the client. Removing the jewelry without consent or postponing the surgery solely due to the presence of religious jewelry are not appropriate actions in this situation.

2. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Avoid lifting more than 10 lb.' After a cataract extraction, the nurse should instruct the client to avoid lifting heavy objects to prevent increased intraocular pressure, which could lead to complications. Choices A, B, and D are incorrect. A - 'Bend at the waist when picking up objects' can increase intraocular pressure; B - 'Avoid lying on the operative side' is not a specific concern related to cataract extraction; D - 'Apply ice to the affected eye' is not a standard post-cataract extraction instruction.

3. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?

Correct answer: A

Rationale: The correct answer is A: 'Assist the patient with comfort measures.' When a patient is experiencing impaired physical mobility due to pain, the priority action is to provide comfort measures to help manage the pain. By addressing the pain, the patient may then feel more comfortable moving and engaging in mobility exercises. Option B, 'Keep the patient as mobile as possible,' could exacerbate the pain and should not be the initial action. While encouraging range of motion (ROM) exercises (Option C) and self-care (Option D) are important aspects of care, addressing pain and comfort should take precedence in this scenario.

4. A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his parents' room. Which of the following actions should the nurse take?

Correct answer: C

Rationale: In this scenario, where the grandparent lacks proper identification, the nurse should respectfully deny the request to take the newborn. It is crucial to prioritize the newborn's safety and security by following hospital policies and procedures. Checking the newborn's identification bracelet against the chart (Choice A) may not be sufficient to address the situation at hand, as the grandparent's lack of identification is the primary concern. While obtaining permission from the newborn's parents (Choice B) is important, the lack of proper identification from the grandparent takes precedence. Reviewing the newborn's footprints record (Choice D) is not necessary in this situation, as the immediate concern is ensuring proper identification and security before allowing the newborn to leave the nursery.

5. How should a healthcare provider respond to a patient who is exhibiting signs of acute myocardial infarction (AMI)?

Correct answer: A

Rationale: When a patient is exhibiting signs of acute myocardial infarction (AMI), the priority action is to call for emergency assistance immediately. This ensures that the patient receives prompt and appropriate care, including interventions such as administering oxygen, nitroglycerin, and monitoring cardiac rhythm. Administering nitroglycerin should only be done if prescribed by a healthcare provider after assessment and confirmation of AMI. Monitoring the patient's cardiac rhythm is important but not the initial action needed in this critical situation. Administering oxygen and preparing for an ECG are important interventions but should follow the immediate step of calling for emergency assistance.

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