A nurse is caring for a client who is 1 day postoperative following a below-the-knee amputation. Which of the following actions should the nurse take?

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ATI Exit Exam 2024 Questions

Question 1 of 5

A nurse is caring for a client who is 1 day postoperative following a below-the-knee amputation. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: The correct action the nurse should take is to place the client in a prone position for 30 minutes four times a day. This position helps prevent contractures after an amputation by stretching the hip flexors and preventing shortening of the residual limb. Keeping the residual limb flat on the bed (Choice A) may lead to contractures. Elevating the residual limb on a pillow (Choice B) can also cause contractures and hinder proper healing. Keeping the residual limb dependent (Choice D) is not recommended as it does not promote proper positioning and circulation.

Question 2 of 5

A nurse is caring for a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

Correct Answer: C

Rationale: The correct answer is to apply the nitroglycerin transdermal patch in the morning and remove it at bedtime. This schedule helps prevent tolerance to the medication. Choice A is incorrect because the patch should be rotated to different sites to prevent skin irritation. Choice B is incorrect as daily rotation is recommended, not daily application to the same site. Choice D is incorrect as the patch should be removed during a bath as it may decrease the efficacy of the medication.

Question 3 of 5

A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse implement?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

A nurse is caring for a client who is receiving continuous enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: The correct action for the nurse to take is to check the placement of the nasogastric tube every 8 hours. This is crucial to ensure that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Administering the feeding using a large-bore syringe (Choice A) is not recommended for enteral nutrition. Flushing the tube with water every 6 hours (Choice C) is not necessary for continuous enteral nutrition. Maintaining the client in an upright position (Choice D) is generally preferred to reduce the risk of aspiration, but it is not the most critical action compared to verifying tube placement.

Question 5 of 5

A nurse is caring for a client who has a prescription for digoxin. Which of the following laboratory values should the nurse monitor to identify an adverse effect of this medication?

Correct Answer: A

Rationale: The correct answer is A: Potassium 3.5 mEq/L. Digoxin can cause hypokalemia as an adverse effect. Monitoring potassium levels is crucial because low potassium levels can increase the risk of digoxin toxicity. Choices B, C, and D are incorrect as they are not directly associated with potential adverse effects of digoxin. Sodium levels are not typically affected by digoxin, calcium levels are not a primary concern with digoxin therapy, and magnesium levels are not the most important to monitor for digoxin adverse effects.

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