what should a nurse do if a patient experiences abdominal cramping during enema administration
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Nursing Elites

ATI RN

ATI Capstone Medical Surgical Assessment 1 Quizlet

1. What should a healthcare professional do if a patient experiences abdominal cramping during enema administration?

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the healthcare professional should lower the height of the enema solution container. This action helps relieve the cramping by slowing down the flow of the enema solution, making it more comfortable for the patient. Stopping the procedure and removing the tubing (Choice B) may be necessary in some cases, but it should not be the first step when cramping occurs. Continuing the enema at a slower rate (Choice C) may exacerbate the cramping, so it is not the best course of action. Increasing the flow of the enema solution (Choice D) will likely worsen the cramping and should be avoided.

2. A patient with pre-dialysis end-stage kidney disease is asking for dietary recommendations. What should the nurse suggest?

Correct answer: D

Rationale: In patients with pre-dialysis end-stage kidney disease, it is crucial to limit phosphorus intake to 700mg/day to manage their condition. High phosphorus levels can lead to complications such as bone and heart problems. Limiting protein intake is essential in later stages of kidney disease, particularly in dialysis patients to reduce the buildup of waste products. While limiting potassium and restricting sodium intake are also important in kidney disease management, the priority for a patient with pre-dialysis end-stage kidney disease is to control phosphorus levels.

3. What lab value should be prioritized for monitoring in a patient with HIV?

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring CD4 T-cell count is crucial in patients with HIV as it reflects the status of their immune system. A CD4 count below 200 cells/mm3 is indicative of severe immunocompromise, necessitating close monitoring and potential intervention. Choices B, C, and D are less specific to HIV management and do not directly reflect the immune status in these patients. Hemoglobin levels are more relevant for assessing anemia, serum albumin levels for nutritional status, and white blood cell count for overall immune response, but none are as directly tied to HIV disease progression as the CD4 T-cell count.

4. What is the primary concern for a patient with a CD4 T-cell count below 180 cells/mm³?

Correct answer: A

Rationale: A CD4 T-cell count below 180 cells/mm³ indicates a severely immunocompromised state, leading to an increased risk of severe infection. In individuals with low CD4 counts, the immune system is significantly weakened, making them more susceptible to opportunistic infections. Anemia (choice B), bleeding (choice C), and dehydration (choice D) are not the primary concerns associated with a low CD4 T-cell count. While these conditions may occur as secondary effects or complications, the primary focus is on preventing and managing severe infections in patients with severely compromised immune systems.

5. A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?

Correct answer: A

Rationale: Choice A is the correct answer because it shows that the client has accepted their disability and is looking towards the future with realistic goals. This positive attitude and focus on engaging in activities that are achievable despite the disability indicate effective coping mechanisms. Choice B is incorrect as it reflects denial of the permanent nature of the disability. Choice C is incorrect as it shows feelings of anger and possible self-blame, which are not indicative of effective coping. Choice D is incorrect as it demonstrates a sense of hopelessness and self-perceived burden, which are signs of maladaptive coping.

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