an elderly female client comes to the clinic for a regular check up the client tells the nurse that she has increased her daily doses of acetaminophen

ATI LPN

ATI Adult Medical Surgical

1. An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client's comment, what previous lab values should the nurse compare with today's lab report?

A. Look at last quarter's hemoglobin and hematocrit to assess for dehydration.
B. Look for an increase in today's LDH compared to the previous one to assess for possible liver damage.
C. Expect to find an increase in today's APTT compared to last quarter's due to bleeding.
D. Determine if there is a decrease in serum potassium due to renal compromise.

Correct answer: B

Rationale: When a client increases their daily doses of acetaminophen for joint pain, it raises concerns about possible liver damage due to acetaminophen overdose. LDH (Lactate Dehydrogenase) levels can indicate liver function, so comparing today's levels with previous ones can help assess for liver damage caused by acetaminophen overuse.

2. A highly successful individual presents to the community mental health center complaining of sleeplessness and anxiety over their financial status. What action should the nurse take to assist this client in diminishing their anxiety?

A. Encourage them to initiate daily rituals.
B. Reinforce the reality of their financial situation.
C. Direct them to drink a glass of red wine at bedtime.
D. Teach them to limit sugar and caffeine intake.

Correct answer: D

Rationale: Teaching the individual to limit sugar and caffeine intake is an appropriate intervention to reduce anxiety and improve sleep quality. Sugar and caffeine can exacerbate anxiety symptoms and disrupt sleep patterns. By reducing their intake, the individual may experience a decrease in anxiety levels and better sleep. Encouraging daily rituals, reinforcing financial realities, or suggesting alcohol consumption before bed are not evidence-based strategies for managing anxiety and sleeplessness.

3. The client has a nasogastric (NG) tube and is receiving enteral feedings. What intervention should the nurse implement to prevent complications associated with the NG tube?

A. Flush the NG tube with water before and after feedings.
B. Check gastric residual volume every 6 hours.
C. Keep the head of the bed elevated at 30 degrees.
D. Replace the NG tube every 24 hours.

Correct answer: C

Rationale: Keeping the head of the bed elevated at 30 degrees is crucial in preventing aspiration, a common complication associated with nasogastric (NG) tubes and enteral feedings. This position helps reduce the risk of reflux and aspiration of gastric contents into the lungs, promoting client safety and preventing respiratory complications. Flushing the NG tube with water before and after feedings (Choice A) is not the primary intervention to prevent complications. Checking gastric residual volume every 6 hours (Choice B) is important but not directly related to preventing complications associated with the NG tube. Replacing the NG tube every 24 hours (Choice D) is not a standard practice and is not necessary to prevent complications if the tube is functioning properly.

4. When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client's vital signs are within normal limits. He reports feeling 'out of breath' but denies any other complaints. What action should the nurse take at this time?

A. Administer a PRN prescription for diphenhydramine (Benadryl).
B. Start the normal saline attached to the Y-tubing at the same rate.
C. Decrease the intravenous flow rate of the PRBC transfusion.
D. Ask the respiratory therapist to administer PRN albuterol (Ventolin).

Correct answer: C

Rationale: In this scenario, the client is experiencing symptoms of shortness of breath, which could indicate fluid overload from the PRBC transfusion. By decreasing the intravenous flow rate of the transfusion, the nurse can slow down the rate of blood being infused, potentially alleviating the symptoms of fluid overload and shortness of breath. This intervention can help prevent further complications and promote the client's comfort and safety.

5. An older adult with a diagnosis of Alzheimer's disease has been experiencing fecal incontinence, with no recent change in stool character noted by the nurse. What is the nurse's most appropriate intervention?

A. Keep a food diary to identify foods that worsen the client's symptoms
B. Provide the client with a bland, low-residue diet
C. Toilet the client on a frequent, scheduled basis
D. Collaborate with the primary provider to secure an order for loperamide

Correct answer: C

Rationale: The most appropriate intervention for an older adult with Alzheimer's disease experiencing fecal incontinence and no change in stool character is to toilet the client on a frequent, scheduled basis. Scheduled toileting can help manage incontinence by establishing a routine for bowel movements, which may aid in reducing episodes of fecal incontinence.