which intervention would be the most important for the nurse to implement for the client with a left nephrectomy
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 2

1. What intervention would be most important for the nurse to implement for the client with a left nephrectomy?

Correct answer: A

Rationale: The correct answer is A: Assess the intravenous fluids for rate and volume. After a nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Choice B is incorrect because changing the surgical dressing daily is important but not the most critical intervention. Choice C is incorrect as monitoring medication levels daily may be necessary but is not the priority after a nephrectomy. Choice D is irrelevant to the immediate postoperative care needed after a nephrectomy.

2. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?

Correct answer: A

Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.

3. The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?

Correct answer: B

Rationale: The correct answer is B: Splenectomy. Splenectomy is the treatment of choice for hereditary spherocytosis as it helps prevent hemolysis and improve anemia. Removing the spleen reduces the destruction of the abnormal red blood cells. Choice A, Bone marrow transplant, is not a standard treatment for hereditary spherocytosis. Choice C, Frequent blood transfusions, may be used to manage anemia in some cases but is not the primary treatment for hereditary spherocytosis. Choice D, Liver biopsy, is not a treatment for hereditary spherocytosis; it is a procedure used to diagnose liver conditions, not related to this hematologic disorder.

4. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

Correct answer: D

Rationale: When a nurse has developed a close relationship with a dying client's family, it is crucial to provide comprehensive support. Encouraging family discussion of feelings helps them express their emotions and concerns, fostering a sense of relief. Accepting the family's experience of anger without judgment validates their emotions and promotes trust. Facilitating the use of spiritual practices identified by the family acknowledges their beliefs and values, offering comfort and solace. Therefore, all of the above interventions are essential in providing holistic care and support during such a challenging time. Choices A, B, and C each play a vital role in addressing different aspects of the family's emotional and spiritual needs, making option D the correct answer.

5. The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?

Correct answer: C

Rationale: The correct method described in option C helps maintain spinal alignment while moving from a lying to a standing position, which is crucial after a lumbar laminectomy with spinal fusion. This technique minimizes strain on the back and promotes safe movement. Choices A, B, and D involve movements that could potentially strain the back, increase the risk of injury, or compromise the spinal alignment, making them less optimal for the client recovering from such surgery.

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