a nurse is providing care for a client with thrombocytopenia which of the following actions should the nurse include
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A nurse is providing care for a client with thrombocytopenia. Which of the following actions should the nurse include?

Correct answer: C

Rationale: The correct action for a nurse caring for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by low platelet count, which can lead to bleeding problems. Providing a stool softener helps prevent constipation, which in turn prevents straining during bowel movements, reducing the risk of bleeding. Encouraging the client to floss daily (Choice A) is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control rather than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is not directly linked to managing thrombocytopenia.

2. A client who is postoperative following a total hip arthroplasty is at risk for hip dislocation. Which of the following actions should the nurse take to prevent this complication?

Correct answer: C

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment and prevents the hip from dislocating. This position aids in keeping the hip in a neutral or slightly outwardly rotated position, reducing the risk of dislocation. Placing the client supine with a pillow between the legs (Choice A) or using a trochanter roll (Choice D) may not provide the same level of abduction and support needed to prevent hip dislocation. Placing a pillow under the client's knees (Choice B) does not provide the necessary support to maintain proper hip alignment in this situation.

3. A client who is at 36 weeks of gestation is scheduled for a nonstress test (NST). Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. The nonstress test typically takes about 10 minutes and evaluates the fetal heart rate in response to fetal movement. Having a full bladder or fasting for 12 hours is not required for a nonstress test. Checking blood glucose levels is not part of the nonstress test procedure.

4. If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?

Correct answer: A

Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.

5. 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.

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