the lpnlvn is caring for a client who has undergone a coronary artery bypass graft cabg surgery which action should the nurse take to prevent postoper
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Nursing Elites

ATI LPN

LPN Pharmacology Assessment A

1. The nurse is caring for a client who has undergone a coronary artery bypass graft (CABG) surgery. Which action should the nurse take to prevent postoperative complications?

Correct answer: A

Rationale: Encouraging the client to cough and deep breathe every 1 to 2 hours is crucial post-CABG surgery to prevent respiratory complications, such as atelectasis and pneumonia. These actions help to expand lung volume, clear secretions, and prevent the collapse of alveoli. Choices B, C, and D are incorrect because maintaining the client in a supine position at all times can lead to complications like decreased lung expansion, keeping the client on bed rest for the first 48 hours may increase the risk of thromboembolism, and restricting fluid intake postoperatively can lead to dehydration and electrolyte imbalances.

2. The client with diabetes mellitus has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?

Correct answer: B

Rationale: Preventing infection is crucial in clients with gangrene to halt the spread of infection and avert further complications. Infections can exacerbate tissue damage and lead to systemic complications, making infection prevention a priority in the care plan for this client. Restoring skin integrity and promoting healing may not be achievable goals until the infection is under control. Improving nutrition is important for overall health but may not be the priority when the immediate concern is preventing infection.

3. A healthcare professional is assessing a client who has a new prescription for levothyroxine. Which of the following findings should the healthcare professional report to the provider?

Correct answer: C

Rationale: The correct answer is C: Heat intolerance. Heat intolerance is a concerning sign of levothyroxine toxicity and should be reported to the provider promptly. Levothyroxine is a medication used to treat hypothyroidism by supplementing the body's thyroid hormones. When a client experiences heat intolerance, it can indicate that the dose of levothyroxine is too high, leading to hyperthyroidism symptoms. Weight gain, increased heart rate, and elevated blood pressure are not typically associated with levothyroxine toxicity; instead, they are more commonly seen in conditions like hypothyroidism.

4. A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?

Correct answer: D

Rationale: In this scenario, the nurse should prioritize educating the client about the effects of cocaine on the heart and provide a referral for further help. This approach is crucial in addressing the root cause of the client's health issues and supporting them in making informed decisions about their health. Reporting the client to the police is not appropriate in this situation as the focus should be on the client's health and well-being. Simply explaining the damage without offering solutions may not effectively address the client's needs or promote holistic care. Telling the client to stop without providing support or education may not be as effective as teaching about the effects of cocaine and offering help for cessation. Therefore, educating about the effects and providing a referral for further assistance is the best course of action for holistic nursing care.

5. While preparing a client for a cardiac catheterization, the client expresses a preference to speak with their doctor rather than the nurse. Which response by the nurse should be therapeutic?

Correct answer: C

Rationale: The therapeutic response by the nurse in this situation involves reflecting the client's feelings back to them, which demonstrates active listening and empathy. By restating the client's preference to talk to their doctor, the nurse acknowledges and validates the client's feelings, thereby fostering a positive therapeutic relationship and promoting open communication. Choices A and B do not acknowledge the client's preference and may come off as dismissive. Choice D is confrontational and defensive, which can lead to a breakdown in communication and trust between the nurse and the client.

Similar Questions

The nurse is caring for a client with coronary artery disease (CAD) who reports chest pain. The nurse administers nitroglycerin as prescribed. What is the next priority action?
A client with chronic obstructive pulmonary disease (COPD) is prescribed theophylline. Which adverse effect should the nurse monitor for that indicates toxicity?
The healthcare professional is assessing a client who presents with jaundice. Which assessment finding is most important for the healthcare professional to follow up on?
A client has a new prescription for heparin. Which of the following laboratory results should be monitored to evaluate the effectiveness of the medication?
The client with a history of angina pectoris is being discharged after coronary artery bypass graft (CABG) surgery. Which statement by the client indicates a need for further teaching?

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