A client is postoperative following a hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?- Skildor

Question 1 of 5

A client is postoperative following a hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

A. Encourage the client to lie flat in bed. B. Apply heat to the incision site. C. Use an abduction pillow between the client's legs. D. Place a trochanter roll under the client's knees.

Correct Answer: C

Rationale: Using an abduction pillow between the client's legs is essential in maintaining proper alignment and preventing dislocation of the hip joint following a hip arthroplasty. Encouraging the client to lie flat in bed (Choice A) is not recommended as early mobilization is crucial for preventing complications. Applying heat to the incision site (Choice B) is not typically done immediately postoperatively. Placing a trochanter roll under the client's knees (Choice D) is not as beneficial as using an abduction pillow to maintain proper positioning.

Question 2 of 5

A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.

A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.' B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.' C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.' D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct Answer: C

Rationale: The correct answer is C. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium and water. Therefore, clients on spironolactone should reduce their intake of foods high in potassium to prevent hyperkalemia. Choices A, B, and D are incorrect because limiting spinach intake due to warfarin, eating anchovies with gout, and taking calcium carbonate with water for osteoporosis do not directly relate to the medication's side effects or dietary restrictions associated with spironolactone.

Question 3 of 5

A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

A. I can give you information about respite care if you are interested. B. You should consider taking a sleeping pill before bed each night. C. It must be difficult taking care of someone who is terminally ill. D. You are doing a great job taking care of your mother.

Correct Answer: A

Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.

Question 4 of 5

A nurse is assessing a newborn immediately following birth. Which of the following findings should the nurse report to the provider?

A. Acrocyanosis B. Vernix caseosa C. A respiratory rate of 50/min D. Heart rate of 160/min

Correct Answer: D

Rationale: The correct answer is D, a heart rate of 160/min. A heart rate of 160/min in a newborn exceeds the normal range and could indicate potential issues that need further evaluation by the provider. Acrocyanosis (choice A) is a common finding in newborns and is not concerning. Vernix caseosa (choice B) is a white, cheesy substance found on newborn skin and is a normal finding. While a respiratory rate of 50/min (choice C) is slightly elevated, it is not as concerning as a high heart rate in a newborn.

Question 5 of 5

A nurse is caring for a client following the application of a cast. Which of the following actions should the nurse take first?

A. Place an ice pack over the cast B. Palpate the pulse distal to the cast C. Teach the client to keep the cast clean and dry D. Position the casted extremity on a pillow

Correct Answer: B

Rationale: Palpating the pulse distal to the cast is the priority as it assesses for circulation. Ensuring adequate blood flow is essential to prevent complications such as compartment syndrome. Placing an ice pack over the cast could cause constriction of blood vessels, further compromising circulation. Teaching the client about cast care and positioning the casted extremity on a pillow are important but do not take precedence over assessing circulation.

ATI Exit Exam 2024

Skildor

ATI RN

ATI RN

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