following a cva the nurse assesses that a client developed dysphagia hypoactive bowel sounds and a firm distended abdomen which prescription for the c following a cva the nurse assesses that a client developed dysphagia hypoactive bowel sounds and a firm distended abdomen which prescription for the c
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ATI LPN

ATI Medical Surgical Proctored Exam 2019 Quizlet

1. Following a CVA, the nurse assesses that a client developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?

Correct answer: A

Rationale: In a client with dysphagia, hypoactive bowel sounds, and a firm, distended abdomen post-CVA, continuous tube feeding at 65 ml/hr via gastrostomy may exacerbate abdominal distension and hypoactive bowel sounds. This situation requires immediate assessment and reevaluation before continuing with the prescription.

2. When transitioning from a long-term care facility to an acute care facility, what does the nurse need to do?

Correct answer: A

Rationale: When transitioning from a long-term care facility to an acute care facility, the nurse needs to adapt motivational approaches. The environment and patient needs change significantly between these settings. Adapting motivational approaches is crucial to effectively meet the demands of the new job and provide optimal care in the acute care setting. This adjustment allows the nurse to cater to the different needs and pace of care required in an acute care facility compared to a long-term care facility. Choices B, C, and D are incorrect as they do not address the specific need for adapting motivational approaches when transitioning between these types of healthcare facilities.

3. A patient is scheduled for cataract surgery but decides to cancel, stating 'I see just fine.' Which of the following responses should the nurse make?

Correct answer: B

Rationale: The correct response is to encourage the patient to share more about their concerns. This approach helps the nurse understand the patient's perspective and allows for a supportive discussion. Choice A is dismissive and does not address the patient's feelings. Choice C may undermine the patient's autonomy and decision-making. Choice D suggests delaying without addressing the patient's current decision.

4. A client is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?

Correct answer: B

Rationale: Diminished deep tendon reflexes are a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to decreased reflexes. Respiratory rate of 12/min, urine output 40 mL/hr, and systolic blood pressure of 140 mm Hg are not specific findings of magnesium toxicity. Respiratory depression, oliguria, and hypotension are more concerning signs that require immediate attention.

5. A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct instruction is to use the peak flow meter after using the rescue inhaler. This ensures accurate monitoring of asthma control during symptoms. Choice A is incorrect because peak flow measurements should be done before taking medications. Choice B is incorrect as the client should blow into the meter quickly and forcefully to get an accurate reading. Choice C is also incorrect as peak flow should be measured regularly, not just when feeling short of breath.

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