a nurse working in a rehabilitation facility is developing a discharge plan for a client who has left sided hemiplegia which of the following actions
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia. Which of the following actions is the nurse's priority?

Correct answer: C

Rationale: The correct answer is C: 'Ensure that the client has a referral for physical therapy.' For a client with left-sided hemiplegia, physical therapy is crucial in restoring function and mobility. It is the nurse's priority to ensure the client receives the necessary rehabilitation services. Consulting with a case manager about insurance coverage (Choice A) is important but not the priority at this stage. Counseling caregivers on respite care options (Choice B) and referring the client to a local stroke support group (Choice D) are also valuable but not as essential as ensuring the client has access to physical therapy for rehabilitation.

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

Correct answer: B

Rationale: The correct answer is B. Clients taking furosemide, a potassium-wasting diuretic, should increase their intake of potassium-rich foods to prevent hypokalemia. Option A is incorrect because weight monitoring is crucial for furosemide due to fluid loss. Option C is incorrect as furosemide is usually taken in the morning to prevent nighttime diuresis. Option D is incorrect because furosemide is best taken on an empty stomach for better absorption.

3. A client practicing Orthodox Judaism informs the nurse they are observing the Passover holiday. Which action should the nurse include in the plan of care?

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism follow dietary restrictions that include consuming unleavened bread. This symbolizes the haste with which the Israelites left Egypt and the lack of time for bread to rise. Providing chicken with cream sauce (Choice A) is not aligned with Passover dietary restrictions. Avoiding serving fish with fins and scales (Choice B) is a general dietary law in Judaism but not specific to Passover. Similarly, avoiding foods containing lamb (Choice D) is not a specific requirement during Passover.

4. A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.

5. A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: Jugular vein distention is a classic sign of left-sided heart failure due to fluid overload in the pulmonary circulation. This occurs because the heart's left side is unable to pump effectively, causing increased pressure in the pulmonary veins and leading to blood backing up into the pulmonary circulation. Peripheral edema (choice A) and dependent edema (choice D) are more commonly associated with right-sided heart failure where blood pools in the systemic circulation, causing swelling in the extremities. Bradycardia (choice B) is not typically a direct consequence of left-sided heart failure; instead, tachycardia is more commonly seen as the heart compensates for its reduced efficiency.

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