ATI RN
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Question 1 of 5
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should monitor for which of the following complications?
Correct Answer: D
Rationale: The correct answer is D: Both B and C. After knee replacement surgery, patients are at risk for developing DVT and pulmonary embolism due to immobility and surgery-related factors. DVT occurs when a blood clot forms in a deep vein, usually in the legs, which can lead to a pulmonary embolism if the clot travels to the lungs. Monitoring for both complications is crucial to prevent serious consequences. Option A, hyperglycemia, is not a common complication following knee replacement surgery and is not directly related to immobility or surgery. Option B, DVT, is correct but does not encompass the risk of pulmonary embolism. Option C, pulmonary embolism, is correct but does not cover the initial risk of DVT formation. Therefore, monitoring for both DVT and pulmonary embolism is essential in post-operative knee replacement patients.
Question 2 of 5
What is the priority nursing intervention for a client with shortness of breath and wheezing?
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help dilate the airways, relieving bronchospasm and improving airflow in clients experiencing shortness of breath and wheezing. This intervention directly addresses the underlying cause of the symptoms. Administering corticosteroids (B) may be considered in severe cases to reduce inflammation but is not the priority initial intervention. Administering pain relief (C) is not indicated unless pain is identified as a contributing factor. Placing the client in a sitting position (D) can help improve breathing but does not directly address the bronchoconstriction causing the wheezing.
Question 3 of 5
Which of the following interventions is most appropriate for a client with a deep wound infection?
Correct Answer: B
Rationale: Step 1: Administering IV antibiotics is important for treating infections, but in this case, the focus is on addressing the pain associated with the deep wound infection. Step 2: Administering pain relief helps improve the client's comfort and quality of life while the infection is being treated. Step 3: Changing the dressing is essential for wound care but does not directly address the client's pain from the infection. Step 4: Performing a CT scan may be necessary to assess the extent of the infection, but it does not directly provide immediate relief for the client's pain. Summary: Administering pain relief is the most appropriate intervention as it directly addresses the client's symptoms and improves their comfort level during the treatment of the deep wound infection.
Question 4 of 5
A nurse is caring for a patient with diabetes who is experiencing symptoms of hypoglycemia. The nurse should:
Correct Answer: B
Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. This is because in hypoglycemia, the patient's blood sugar levels are low and need to be raised quickly to avoid serious complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (choice A) would further lower blood sugar levels, monitoring without intervention (choice C) could lead to worsening symptoms, and administering an oral hypoglycemic agent (choice D) may not act quickly enough to raise blood sugar levels in an emergency situation.
Question 5 of 5
What is the first step in managing a client with an asthma attack?
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. The first step in managing an asthma attack is to address the underlying cause, which is airway constriction. Bronchodilators help relax the muscles around the airways, making it easier for the client to breathe. Providing oxygen therapy (B) can be helpful but addressing airway constriction is the priority. Administering analgesics (C) or pain medication (D) is not appropriate as asthma attacks are not typically associated with pain.
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