ATI PN Adult Medical Surgical Online Practice 2020 B

A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan? Measure rectal temperature every 4 hr. Remind the client to cough as needed. Use a turn sheet to reposition the client. Apply wrist restraints. -…CORRECT ANSWER100% Use a turn sheet to reposition the client. Rationale: Change client's position slowly to prevent sudden (+) in ICP. Turn sheet gives the nurse better control of the client's movement and alignment. A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan? Massage both lower extremities to promote comfort. Begin the client on a regular diet when the gag reflex returns. Encourage the client to use the incentive spirometer every 4 hr while awake. Assist the client to change positions at least every 2 hr. -…CORRECT ANSWER100% Assist the client to change positions at least every 2 hr. Rationale: To promote return of respiratory function following anesthesia and prevent atelectasis (partial or complete collapse of the lung) and pneumonia. A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain? Semi-Fowler's Supine with lower extremities elevated Upright, leaning forward Side-lying with knees bent -…CORRECT ANSWER100% Upright, leaning forward Rationale: upright position, leaning forward, to facilitate breathing and decrea