a nurse is reviewing the lab results of a client with liver disease which finding requires immediate intervention
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. A healthcare professional is reviewing the lab results of a client with liver disease. Which finding requires immediate intervention?

Correct answer: C

Rationale: Elevated ammonia levels in a client with liver disease can lead to hepatic encephalopathy, requiring immediate intervention. Ammonia is a neurotoxin that can cause cognitive impairment and altered mental status. Elevated bilirubin levels (Choice A) are common in liver disease but do not require immediate intervention. Low albumin levels (Choice B) and low hemoglobin levels (Choice D) are also common in liver disease but do not pose an immediate threat compared to elevated ammonia levels.

2. What is the priority when assessing a patient for possible deep vein thrombosis (DVT)?

Correct answer: B

Rationale: The correct answer is to measure the calf circumference of both legs when assessing a patient for possible DVT. An increase in calf circumference in one leg can indicate the presence of a DVT. Option A is incorrect because dorsiflexing the foot and checking for pain are not primary assessments for DVT. Option C is incorrect as redness of the skin may not always be present in cases of DVT. Option D is incorrect as performing a Doppler ultrasound scan is usually done after clinical assessment and to confirm the diagnosis, not as the initial priority assessment.

3. What is the most appropriate action for a healthcare professional to take when a medication error occurs?

Correct answer: B

Rationale: When a medication error occurs, the most appropriate action for a healthcare professional is to report the error to the healthcare provider immediately. This is crucial for ensuring prompt corrective action to mitigate any potential harm to the patient. Documenting the error is important but should come after reporting it to the relevant authorities. Apologizing to the patient is important for maintaining trust and communication but should not take precedence over reporting and addressing the error. Continuing to administer the medication without addressing the error is unsafe and goes against patient safety protocols.

4. What are the key considerations when administering opioid analgesics to a patient in pain?

Correct answer: A

Rationale: The correct key consideration when administering opioid analgesics to a patient in pain is monitoring for respiratory depression. Opioids can lead to respiratory depression, making it crucial to carefully monitor the patient's breathing. Administering an opioid antagonist is not a key consideration during the administration of opioids; it is used to reverse opioid effects in cases of overdose, not as a routine practice. Assessing respiratory rate and pain level before administration is important but not the key consideration compared to monitoring for respiratory depression. Monitoring the patient's level of consciousness is also essential but not as critical as monitoring for respiratory depression when administering opioids.

5. When teaching a patient about self-administration of insulin, what is the most important instruction to provide?

Correct answer: A

Rationale: The most important instruction to provide when teaching a patient about self-administration of insulin is to rotate injection sites to prevent tissue damage. Rotating injection sites helps prevent lipodystrophy (tissue damage) and ensures proper insulin absorption. Option B is incorrect because the angle of insulin injection varies depending on the patient's body composition. Injecting at a 90-degree angle is not always necessary. Option C is not the most crucial instruction; while storing insulin in the refrigerator is important, it is not the priority when teaching self-administration. Option D is also important for maintaining consistency but is not as critical as rotating injection sites to prevent tissue damage.

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