an unlicensed assistive personnel uap reports to the charge nurse that a client who delivered a 7 pound infant 12 hours ago is complaining of a severe
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ATI Medical Surgical Proctored Exam 2019 Quizlet

1. A client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6ยบ F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the healthcare team implement first?

Correct answer: B

Rationale: The correct action to implement first is to determine if the client received anesthesia during delivery. Anesthesia can be a potential cause of postpartum headaches. This information is crucial in assessing and managing the client's condition effectively before considering other interventions. It helps in identifying possible contributing factors to the client's complaint of a severe headache and guides the healthcare team in providing appropriate care and treatment.

2. The client has acute kidney injury (AKI). Which assessment finding requires immediate intervention?

Correct answer: B

Rationale: An elevated serum potassium level of 6.2 mEq/L in a client with AKI can lead to life-threatening cardiac arrhythmias, necessitating immediate intervention. Hyperkalemia is a serious complication in AKI as impaired kidney function can result in the accumulation of potassium in the blood, posing a risk of cardiac arrest. Prompt treatment to lower potassium levels is crucial to prevent cardiac complications in this situation.

3. A client with cirrhosis of the liver is being cared for by the healthcare team. Which clinical manifestation indicates that the client has developed hepatic encephalopathy?

Correct answer: A

Rationale: Asterixis, also known as flapping tremor, is a characteristic sign of hepatic encephalopathy, a severe complication of liver cirrhosis. Hepatic encephalopathy results from the liver's inability to detoxify substances in the body, leading to neurologic manifestations such as changes in mental status, confusion, and asterixis.

4. A patient with hyperthyroidism is to receive radioactive iodine therapy. What information should the nurse include in the patient teaching plan?

Correct answer: A

Rationale: The correct answer is to avoid close contact with pregnant women for one week. This precaution is essential to prevent radiation exposure to vulnerable populations. Pregnant women and small children are more sensitive to radiation, making it crucial for patients undergoing radioactive iodine therapy to avoid close contact with them for a specified period. Choices B, C, and D are incorrect because taking iodine supplements daily is not necessary for patients receiving radioactive iodine therapy. Restricting fluid intake to 1 liter per day is not a standard recommendation for radioactive iodine therapy. Using disposable utensils for all meals is not a specific precaution related to radioactive iodine therapy.

5. What is the most appropriate nursing intervention to help alleviate severe abdominal pain in a patient with acute pancreatitis?

Correct answer: C

Rationale: Administering prescribed opioid analgesics is the most appropriate nursing intervention to alleviate severe abdominal pain in a patient with acute pancreatitis. Opioid analgesics help manage severe pain effectively in such cases. Encouraging oral intake of clear fluids with electrolytes is contraindicated due to the need for pancreatic rest and potential exacerbation of symptoms. Placing the patient in a semi-Fowler's position helps reduce pressure on the abdomen, unlike a supine position that can worsen the pain. Applying a cold pack is not recommended as it can potentially increase discomfort and vasoconstriction in acute pancreatitis.

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