ATI RN
ATI Perfusion Quizlet
1. The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?
- A. Check frequently for swollen lymph nodes.
- B. Watch for excessive bleeding or bruising.
- C. Take iron supplements to prevent anemia.
- D. Wash hands regularly and avoid individuals who are ill.
Correct answer: D
Rationale: The correct answer is D: 'Wash hands regularly and avoid individuals who are ill.' After a splenectomy, the patient is at an increased risk of infection, particularly from gram-positive bacteria. Proper hand hygiene and avoiding contact with sick individuals are crucial to prevent infections. Choices A, B, and C are incorrect because checking for swollen lymph nodes, watching for excessive bleeding or bruising, and taking iron supplements are not specifically related to the increased infection risk post-splenectomy.
2. A client is prescribed furosemide and needs to consume potassium-rich foods. Which of the following foods should the client be advised to include in the diet?
- A. Grapes.
- B. Apples.
- C. Bananas.
- D. Rice.
Correct answer: C
Rationale: The correct answer is C: Bananas. Bananas are rich in potassium and should be included in the diet of clients taking furosemide, a potassium-wasting diuretic. Grapes, apples, and rice are not as high in potassium as bananas and would not be as effective in replenishing potassium levels in clients taking furosemide.
3. The nurse is teaching a patient with cancer about a new prescription for a fentanyl patch, 25mcg/hr. for chronic back pain. Which statement is the most appropriate to include in the teaching plan.
- A. You will need to change this patch every day, regardless of your pain level.
- B. This type of pain medication is not as likely to cause breathing problems.
- C. With the first patch, it will take about 24hrs before you feel the full effects.
- D. Use your heating pad for the back pain. It will also improve the patch�s effectiveness.
Correct answer: C
Rationale: Full analgesic effects can take up to 24 hours to develop with fentanyl patches. Most patches are changed every 72 hours. Has the same adverse effects as other opioids, including respiratory depression. Should avoid exposing the patch to external heat sources, because this may increase toxicity.
4. The nurse is administering a beta blocker to a client with a heart rate of 50 bpm. What is the priority action?
- A. Hold the beta blocker and notify the healthcare provider.
- B. Administer the beta blocker as ordered.
- C. Decrease the dose of the beta blocker.
- D. Monitor the client’s heart rate and reassess in 30 minutes.
Correct answer: A
Rationale: The correct action is to hold the beta blocker and notify the healthcare provider. A heart rate of 50 bpm is already low, and beta blockers can further decrease the heart rate, potentially causing adverse effects like bradycardia or heart block. Administering the beta blocker as ordered (Choice B) can exacerbate the low heart rate. Decreasing the dose of the beta blocker (Choice C) may not be sufficient to address the potential harm. Monitoring the client’s heart rate and reassessing in 30 minutes (Choice D) may delay necessary interventions if the heart rate drops further. Therefore, the priority is to hold the medication and seek guidance from the healthcare provider.
5. A nurse is reviewing a client's health history and identifies urinary incontinence as a risk factor for pressure injuries. What should the nurse include in the plan of care?
- A. Use a heating pad for comfort
- B. Apply a barrier cream to the skin
- C. Reposition the client every 4 hours
- D. Change the client's position every 2 hours
Correct answer: C
Rationale: The correct answer is to reposition the client every 4 hours. Repositioning the client helps prevent pressure injuries caused by urinary incontinence by relieving pressure on vulnerable areas of the skin. Choice A, using a heating pad for comfort, is not directly related to preventing pressure injuries. Choice B, applying a barrier cream to the skin, may help protect the skin but does not address the underlying cause of pressure injuries. Choice D, changing the client's position every 2 hours, is more frequent than necessary and may not be as effective in preventing pressure injuries as repositioning every 4 hours.
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