the nurse instructs the patient about incentive spirometry as preoperative teaching which phase of the nursing process does this illustrate
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form B

1. The nurse instructs the patient about incentive spirometry as part of preoperative teaching. Which phase of the nursing process does this illustrate?

Correct answer: C

Rationale: Instructing a patient about incentive spirometry falls under the implementation phase of the nursing process. During this phase, nursing interventions are put into action. Assessment (choice A) involves collecting data about the patient's condition, planning (choice B) involves setting goals and creating a care plan, and evaluation (choice D) involves assessing the outcomes of nursing interventions. Therefore, the correct answer is C, as it reflects the active teaching and intervention part of the process.

2. A client newly diagnosed with nephrotic syndrome is being taught by a nurse. Which statement indicates that the client understands the teaching?

Correct answer: A

Rationale: The correct answer is A: “I can expect swelling in my hands and on my face.” Nephrotic syndrome leads to increased permeability of the glomeruli, resulting in edema, especially in the face and dependent areas. Choice B is incorrect because nephrotic syndrome leads to protein loss in the urine, not an increase in blood protein levels. Choice C is incorrect as stomach pain and gas are not typical symptoms of nephrotic syndrome. Choice D is unrelated to the teaching about nephrotic syndrome and gum bleeding.

3. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

Correct answer: B

Rationale: The correct answer is B. A urine specific gravity of 1.001 is low and indicates dilute urine, which is a sign of fluid overload (hypervolemia). Choice A, serum sodium 138 mEq/L, is within the normal range and does not indicate hypervolemia. Choice C, serum calcium 10 mg/dL, is not typically used to diagnose hypervolemia. Choice D, urine pH 6, is also not a specific indicator of hypervolemia.

4. A home health nurse is providing teaching to a patient who has a new diagnosis of a gastric ulcer and a new prescription for sucralfate oral suspension. What statement by the patient indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because sucralfate should be taken on an empty stomach, 1 hour before meals, and at bedtime to coat the ulcer and protect it from stomach acid. Choice A is incorrect because taking it with meals may reduce its effectiveness. Choice B is incorrect as it should not be taken right before bed. Choice D is incorrect as sucralfate should be taken regularly as prescribed, not just when symptoms occur.

5. A healthcare provider is assessing a client who is receiving heparin therapy for deep vein thrombosis (DVT). Which of the following laboratory values should the provider monitor to evaluate the therapeutic effect of the heparin?

Correct answer: B

Rationale: The Partial Thromboplastin Time (PTT) is the correct laboratory value to monitor heparin therapy. PTT measures the time it takes for blood to clot and is specifically used to evaluate the effectiveness of anticoagulation therapy such as heparin. Monitoring the PTT helps ensure that the heparin dose is within the therapeutic range. Platelet count, Prothrombin time (PT), and Bleeding time are not specific laboratory values for monitoring the therapeutic effect of heparin therapy. Platelet count is more indicative of platelet function, PT is used to monitor warfarin therapy, and Bleeding time assesses platelet function rather than the effect of heparin therapy.

Similar Questions

A nurse is providing teaching about breastfeeding to a client who is postpartum. Which of the following instructions should the nurse include?
A client is found on the floor of their room experiencing a seizure. Which of the following actions is the priority for the nurse?
A client with rheumatoid arthritis is taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?
A nurse is caring for a client prescribed montelukast. Which of the following should the nurse include in teaching related to this medication?
A client with a new diagnosis of hypertension is being taught about lifestyle modifications by a nurse. What dietary change should the nurse recommend?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses