a nurse is providing discharge teaching to a client who is postoperative following a mastectomy which of the following instructions should the nurse i
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Nursing Elites

ATI RN

ATI Exit Exam RN

1. A nurse is providing discharge teaching to a client who is postoperative following a mastectomy. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction for the nurse to include is to advise the client to avoid using deodorant until the incision heals. Using deodorant can lead to skin irritation, which should be prevented following a mastectomy. Choice B is incorrect because performing arm exercises should typically be delayed until recommended by the healthcare provider to prevent strain on the surgical site. Choice C is incorrect as tight-fitting clothing can increase discomfort and hinder proper healing. Choice D is also incorrect because initiating arm exercises should be based on the healthcare provider's guidance and not a specific timeframe.

2. A client has a new prescription for furosemide. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is to instruct the client to take furosemide with a full glass of water in the morning. Furosemide is a diuretic that can cause increased urination, so it is best taken earlier in the day to avoid disrupting sleep with nocturia. Choice B is not the priority instruction for furosemide. Choice C is incorrect as taking furosemide at bedtime can lead to nocturia, which is undesirable. Choice D is incorrect because furosemide can be taken with or without food.

3. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

Correct answer: C

Rationale: When caring for a client with bipolar disorder experiencing acute mania and having obtained a verbal prescription for restraints, the nurse must ensure to obtain a formal written prescription for restraint within 4 hours. This is crucial to maintain the safety and proper care of the client. Choices A, B, and D are incorrect because renewing the prescription every 8 hours, checking pulse rate every 30 minutes, and documenting the client's condition every 15 minutes do not address the immediate need for a formal restraint prescription within 4 hours to manage the client's acute mania effectively.

4. A nurse is caring for a client who has cirrhosis. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: In clients with cirrhosis, the liver is unable to produce clotting factors efficiently, leading to impaired clotting function. Therefore, an increased prothrombin time is expected in cirrhosis. Choices A, B, and C are incorrect. Decreased bilirubin levels are not typically seen in cirrhosis; prothrombin time is usually increased, not decreased; and albumin levels are often decreased in cirrhosis due to reduced synthetic liver function.

5. A client with iron-deficiency anemia is being taught about dietary management by a nurse. Which of the following foods should the nurse recommend?

Correct answer: B

Rationale: The correct answer is B: Red meat. Red meat is a good dietary source of heme iron, which is easily absorbed by the body and beneficial for individuals with iron-deficiency anemia. Oatmeal, bananas, and whole grains are not as rich in iron compared to red meat and may not provide sufficient amounts to help manage iron-deficiency anemia effectively.

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