Question 1:
A nurse is caring for a client who has undergone a total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthetic hip?
A) Maintain the affected hip in adduction.
B) Encourage the client to cross the legs while sitting.
C) Avoid ...
pg. 1 ATI RN COMPREHENSIVE EXIT EXAM LATEST VER SION 180 ACTUAL Q&A Question 1: A nurse is caring for a client who has undergone a total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthetic hip? A) Maintain the affected hip in adduction. B) Encourage the client to cross the legs while sitting. C) Avoid placing a pillow between the client's legs when turning. D) Instruct the client to flex the hip greater than 90 degrees when sitting. Answer: C) Avoid placing a pillow between the client's legs when turning. Explanation: Placing a pillow between the legs when turning can cause abduction of the hip, increasing the risk of dislocation after hip arthroplasty. The nurse should avoid this action to prevent complications. Question 2: A nurse is caring for a client who has a nasogastric tube in place for gastric decompression. Which of the following interventions should the nurse implement to maintain tube patency? A) Irrigate the tube with water every 4 hours. B) Clamp the tube when not in use to prevent air entry. C) Rotate the tube 180 degrees every 8 hours. D) Monitor gastric pH every 2 hours. pg. 2 Answer: A) Irrigate the tube with water every 4 hours. Explanation: Regular irrigation with water helps prevent the accumulation of gastric contents and maintains tube patency in clients with nasogastric tubes for gastric decompression. Question 3: A nurse is caring for a client who has a prescription for enoxaparin sodium (Lovenox) subcutaneous injections. Which of the following actions should the nurse take? A) Aspirate for blood return after injecting the medication. B) Massage the injection site after administering the medication. C) Administer the medication into the deltoid muscle. D) Apply pressure to the injection site after administering the medication. Answer: D) Apply pressure to the injection site after administering the medication. Explanation: Applying pressure to the injection site after administering enoxaparin sodium helps prevent bruising and hematoma formation. Massaging the site or aspirating for blood return is not recommended for subcutaneous injections of this medication. Question 4: A nurse is caring for a client who has a new prescription for clopidogrel (Plavix). The nurse should instruct the client to report which of the following findings immediately? A) Fever pg. 3 B) Constipation C) Sore throat D) Headache Answer: C) Sore throat Explanation: Clopidogrel can cause neutropenia, which may present with symptoms such as sore throat, fever, and other signs of infection. Clients should report these findings immediately to their healthcare provider. Question 5: A nurse is caring for a client who is receiving continuous enteral feedings via a nasogastric tube. Which of the following interventions should the nurse implement to prevent aspiration pneumonia? A) Elevate the head of the bed to at least 30 degrees during feedings and for 1 hour afterward. B) Use a small -bore feeding tube to decrease the risk of aspiration. C) Administer the enteral feeding at room temperature. D) Flush the nasogastric tube with 30 mL of water before and after administering medication. Answer: A) Elevate the head of the bed to at least 30 degrees during feedings and for 1 hour afterward. Explanation: pg. 4 Elevating the head of the bed to at least 30 degrees during enteral feedings and for 1 hour afterward helps prevent aspiration pneumonia by reducing the risk of regurgitation and aspiration of gastric contents. Question 6: A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central venous catheter. The nurse should monitor the client for which of the following complications? A) Hypoglycemia B) Hypovolemia C) Hypernatremia D) Hyperkalemia Answer: C) Hypernatremia Explanation: Clients receiving TPN are at risk for hypernatremia due to the high sodium content of the solution. The nurse should monitor serum sodium levels closely and assess for signs and symptoms of hypernatremia. Question 7: A nurse is caring for a client who is prescribed warfarin (Coumadin) therapy. The nurse should instruct the client to avoid which of the following foods? A) Green leafy vegetables B) Lean meats C) Whole grains D) Citrus fruits
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