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 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.

3. The two members of the health care team who work closely to monitor drug-nutrient interactions are:

Correct answer: D

Rationale: Clinical dietitians and pharmacists work together to manage drug-nutrient interactions. They have the expertise to understand how medications and nutrients can interact in the body, potentially affecting the effectiveness of treatment. Physicians and nurses may be involved in patient care, but when it comes to monitoring drug-nutrient interactions, the specialized knowledge of clinical dietitians and pharmacists is crucial. Nurses and physicians typically focus more on administering medications and managing overall patient care, rather than the specific interactions between drugs and nutrients.

4. For a patient on lithium therapy, which dietary recommendation is essential?

Correct answer: B

Rationale: The correct answer is to increase sodium intake. For patients on lithium therapy, maintaining consistent sodium intake is crucial to avoid fluctuations in drug levels. Increasing caffeine intake (choice A) is not recommended as it can interfere with lithium levels. While protein intake (choice C) is important for overall health, it is not specifically essential for patients on lithium therapy. Similarly, increasing fiber intake (choice D) is beneficial but not a primary concern for patients on lithium therapy.

5. Which of the following describes the four-step method of assessment, planning, implementation, and evaluation?

Correct answer: C

Rationale: The correct answer is C: 'It is a circular process of continued nursing care.' The four-step method of assessment, planning, implementation, and evaluation in nursing is a continuous and cyclical process. Choice A is incorrect because the method is not solely problem-focused; it involves a comprehensive approach. Choice B is incorrect as it does not capture the cyclical nature of the process. Choice D is incorrect as the method is systematic and not based on trial-and-error but rather evidence-based practice.

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