The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?- Skildor

Question 1 of 5

The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

A. Establish a rapport with the client to decrease embarrassment during site assessment B. Encourage the client to lie in the lithotomy position twice a day C. Milk the tube inserted during surgery to facilitate the passage of flatus D. Digitally dilate the rectal sphincter to express old blood

Correct Answer: A

Rationale: Establishing rapport with the client is crucial in postoperative care to create a trusting relationship, reduce embarrassment, and enhance comfort during assessments. Encouraging the client to lie in the lithotomy position is not recommended after a hemorrhoidectomy as it can be uncomfortable and may disrupt wound healing. Milking the tube inserted during surgery is not a standard practice and could lead to complications. Digitally dilating the rectal sphincter is not indicated post-hemorrhoidectomy and can cause harm to the client.

Question 2 of 5

The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?

A. The client's BP is 110/70 B. The client's potassium level is 3.4 mEq/L C. The client has a barky cough D. The client's apical pulse is 56

Correct Answer: D

Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering a beta blocker as the blood pressure is within normal range. Choice B is not directly related to the administration of a beta blocker. Choice C may indicate a potential adverse effect of another medication, but it does not specifically warrant questioning the administration of the beta blocker.

Question 3 of 5

A client has been given instructions about ferrous sulfate. Which statement made by the client would indicate the client needs further education?

A. I will take this medication on an empty stomach. B. I will take the morning dose 1 hour before breakfast. C. I will need to avoid taking this medication with coffee. D. I will take antacids if needed, 2 hours after I take ferrous sulfate.

Correct Answer: A

Rationale: The correct answer is A. Ferrous sulfate should be taken on an empty stomach to improve absorption. Choice A is incorrect as taking the medication with a full glass of milk would impair iron absorption. Choices B, C, and D are all correct statements regarding the administration of ferrous sulfate. Choice B ensures proper timing before breakfast, choice C highlights avoiding coffee due to interference with iron absorption, and choice D correctly suggests taking antacids a few hours after ferrous sulfate to prevent potential interactions.

Question 4 of 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?

A. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor B. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes C. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk D. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress

Correct Answer: C

Rationale: Choice C is the best direction provided by the nurse. This method involves reaching over to the left side rail with the right hand, pulling the body onto its side, bending the upper leg so the foot is on the bed, and pushing down to elevate the trunk. This approach helps maintain spinal alignment while moving from a lying to a standing position, reducing strain on the back. Choices A, B, and D involve movements that are not suitable for a client recovering from a lumbar laminectomy with spinal fusion and could potentially cause harm or discomfort.

Question 5 of 5

What instructions should the nurse discuss with the client diagnosed with Raynaud's phenomenon?

A. Explain that exacerbations will not occur in the summer B. Use nicotine gum to help quit smoking C. Wear extra warm clothing during cold exposure D. Avoid prolonged exposure to direct sunlight

Correct Answer: C

Rationale: The correct answer is to wear extra warm clothing during cold exposure. This instruction is crucial for managing Raynaud's phenomenon as it helps prevent vasospasms triggered by cold temperatures. Choice A is incorrect because exacerbations can occur in any season. Choice B is not directly related to managing Raynaud's phenomenon. Choice D is also irrelevant as direct sunlight exposure does not typically worsen symptoms of Raynaud's phenomenon.

ATI RN Custom Exams Set 1

Skildor

ATI RN

ATI RN

ATI RN Custom Exams Set 1 Questions

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