ATI Learning System PN Medical Surgical Final Quizlet

Correct Answer: D

Rationale: The nurse's priority action in this situation is to notify the healthcare provider immediately. These symptoms, including severe pain, swelling, warmth, and redness in the leg, are indicative of deep vein thrombosis (DVT), a potentially serious condition. Prompt notification of the healthcare provider is crucial to initiate appropriate diagnostic tests and interventions to prevent complications associated with DVT.

Correct Answer: C

Rationale: It is crucial for patients undergoing external beam radiation therapy to avoid exposing the treated area to sunlight as it can lead to further skin damage. Heat sources like heating pads should be avoided to prevent potential burns. Alcohol-based lotions can irritate the skin, so they should not be used. Washing the treated area with lukewarm water and mild soap is recommended to maintain skin integrity and prevent irritation.

Correct Answer: A

Rationale: When educating a patient prescribed allopurinol for gout, the nurse should emphasize taking the medication with food to reduce the risk of gastrointestinal upset. It is important to instruct the patient to maintain adequate hydration by consuming plenty of fluids, preferably water, to help prevent kidney stone formation and facilitate the drug's effectiveness. Allopurinol does not provide immediate pain relief but rather works to lower uric acid levels over time, reducing the frequency of gout attacks.

Correct Answer: A

Rationale: The priority nursing action for a patient with type 1 diabetes mellitus admitted with diabetic ketoacidosis (DKA) is to administer regular insulin intravenously. Insulin helps to lower blood glucose levels and correct acidosis, which are critical in managing DKA. Oral hypoglycemic agents are not appropriate in the acute setting of DKA as they may not work quickly enough. Sodium bicarbonate may be used in some cases to correct acidosis, but insulin administration takes precedence. Providing a high-calorie diet is not appropriate initially in DKA management, as the focus is on stabilizing the patient's condition through insulin therapy and fluid/electrolyte correction.

Correct Answer: B

Rationale: Jaundice in a client with liver cirrhosis is primarily caused by increased bilirubin levels. In liver cirrhosis, the impaired liver function leads to the accumulation of bilirubin in the blood, resulting in jaundice. Bilirubin is a yellow pigment produced from the breakdown of red blood cells, and its elevation is a common manifestation of liver dysfunction.