when palpating the clients neck for lymphadenopathy where should the nurse position himself
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. When palpating the client's neck for lymphadenopathy, where should the nurse position himself?

Correct answer: D

Rationale: When palpating the client's neck for lymphadenopathy, the nurse should position himself in front of a sitting client. This positioning allows for easier access to the neck area and better visualization of any swelling or abnormalities in the lymph nodes. Being in front of the client ensures proper alignment and comfort for both the nurse and the client during the assessment. Choices A, B, and C are incorrect because positioning at the client's back or sides would make it challenging to adequately palpate the neck area and assess for lymphadenopathy.

2. The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?

Correct answer: B

Rationale: The correct answer is to assess the client for a pulse. In ventricular tachycardia, the priority is to determine if the client has a pulse. If there is no pulse, immediate initiation of CPR with chest compressions is required. Calling a code or continuing to monitor the client can delay life-saving interventions. Therefore, assessing for a pulse is the most crucial step in managing ventricular tachycardia.

3. A patient with hypothyroidism should be advised to consume more of which nutrient?

Correct answer: B

Rationale: The correct answer is B: Iodine. Iodine is crucial for the production of thyroid hormones. A deficiency in iodine can lead to hypothyroidism. Calcium (Choice A) is important for bone health but is not directly related to thyroid function. Vitamin C (Choice C) is essential for the immune system and skin health but does not play a significant role in thyroid function. Iron (Choice D) is vital for red blood cell production and oxygen transport but is not specifically relevant to hypothyroidism.

4. Determining nursing care priorities is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

Correct answer: B

Rationale: Corrected Rationale: Planning in nursing involves setting priorities based on the identified patient needs, establishing goals, and developing a plan of care. Evaluation involves assessing the effectiveness of the care provided, implementation is the phase where the care plan is carried out, and assessment is the initial step of collecting data to identify the patient's needs. Therefore, in the context of determining nursing care priorities, the correct step is Planning (choice B).

5. The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow-up?

Correct answer: B

Rationale: An HbA1c of 7.0% in a client with diabetes mellitus indicates poor long-term glucose control, necessitating immediate follow-up. Choice A, chronic kidney disease with a serum creatinine of 1.6 mg/dL, though concerning, does not indicate an immediate need for follow-up. Choice C, heart failure with a BNP of 140 pg/mL, may require monitoring but not immediate follow-up. Choice D, a male client with anemia and normal hemoglobin and hematocrit levels, does not warrant immediate attention based on the provided information.

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