ATI RN Adult Medical Surgical Practice with NGN

ATI RN Adult Medical Surgical Practice with NGN A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? Anorexia Abdominal pain radiating to the right shoulder Tachycardia Rebound abdominal tenderness Tachycardia -Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and tingling sensation in their hands. Which of the following medications should the nurse plan to administer? Epoetin alfa Furosemide Captopril Calcium carbonate Calcium carbonate A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? -Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. -Assist the client to start arm exercises 48 hr after surgery. -Maintain the right arm in an extended position at the client's side when in bed. -Place the client in a supine position for the first 24 hr after surgery. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. -drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period. Rationale -start exercising the right arm 24 hr after surgery. -elevate the client's right arm on a pillow to promote lymphatic fluid return. -elevate the head of the client's bed to at least 30° to promote drainage from the surgical site and facilitate breathing. A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? -Shellfish -Peanuts -Eggs -Avocados Avocados -avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity. Rationale -egg and peanut allergy might have an allergic reaction to propofol. -shellfish allergy might have an allergic reaction to povidone-iodine. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? -Remove the client's indwelling urinary catheter. -Irrigate the indwelling urinary catheter. -Clamp the indwelling urinary catheter. -Apply traction to the indwelling urinary catheter. Irrigate the indwelling urinary catheter. -irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow. Rationale -Clamping the urinary catheter can increase pressure inside the client's bladder and cause internal bleeding. -apply traction to the catheter to reduce the risk for bleeding, but this action will not clear the tubing of an obstruction. A nurse is providing teaching to a client who has AIDs. Which of the following statements by the client indicates an understanding of the teaching? -"I should clean my toothbrush in the dishwasher once a month." -"I should eat more fresh fruit and vegetables." -"I will avoid drinking a glass of cold liquid that has been standing for 30 minutes." -"I will take my temperature once a day." "I will take my temperature once a day." -AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection. Rationale -client should avoid drinking a glass of liquid that stands for 60 min or more to reduce the risk of drinking contaminated liquids. -should avoid eating raw fruits and vegetables that can contain bacteria and cause infection. The nurse should advise the client to eat a low-bacteria diet. -should clean their toothbrush weekly in the dishwasher or in a bleach solution to destroy micro-organisms. A nurse is providing teaching to a client who has irritable bowel syndrome IBS. Which of the following instructions should the nurse include in the teaching? -Take an antacid before meals and at bedtime. -Increase fiber intake to at least 30 g per day. -Drink ginger tea daily. -Consume no more than 1 L of water per day. Increase fiber intake to at least 30 g per day. -Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns Rationale -Antacids are used to manage manifestations of gastric reflux and dyspepsia, not cramps and pain associated with diarrhea and constipation. -Ginger tea is useful for treating nausea, not cramping. client who has IBS should avoid dairy products, raw fruits, and grains that can cause bloating. -should consume at least 2 L of water daily to promote regular bowel function. A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates and understanding of the teaching? -"I will take my iron with a glass of milk." -"I will take an antacid with my iron." -"I will limit my intake of red meat." -"I will eat more high-fiber foods." "I will eat more high-fiber foods." -eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.