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ATI PN Comprehensive Predictor 2023 Quizlet
1. A healthcare provider is assessing a client who has received a preoperative dose of morphine. Which of the following findings is the priority to report to the provider?
- A. Client reports nausea.
- B. Urinary output of 20 mL/hr.
- C. Oxygen saturation 90%.
- D. Respiratory rate 14/min.
Correct answer: C
Rationale: An oxygen saturation of 90% is below the expected reference range and could indicate respiratory depression, a serious side effect of morphine. This finding requires immediate attention as it may lead to hypoxia. Nausea (choice A) is a common side effect of morphine but does not pose an immediate threat. A urinary output of 20 mL/hr (choice B) may indicate decreased renal perfusion but is not as critical as respiratory compromise. A respiratory rate of 14/min (choice D) is within the normal range and does not suggest immediate danger.
2. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?
- A. Irrigate the nasogastric tube with distilled water
- B. Aspirate the gastric contents with a syringe
- C. Administer an antiemetic medication
- D. Insert a new nasogastric tube
Correct answer: B
Rationale: The most appropriate nursing intervention when a client with a nasogastric tube experiences nausea and a decrease in gastric secretions is to aspirate the gastric contents with a syringe. This action helps relieve nausea by removing excess fluid and gas. Option A, irrigating the nasogastric tube with distilled water, is not indicated as it does not address the underlying issue of decreased gastric secretions. Option C, administering an antiemetic medication, may provide symptomatic relief but does not address the mechanical issue of decreased flow in the nasogastric tube. Option D, inserting a new nasogastric tube, is not necessary unless there are specific complications or obstructions in the current tube.
3. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following actions should the nurse take?
- A. Administer insulin
- B. Administer glucagon
- C. Administer 4 oz of orange juice
- D. Administer 1 L of water
Correct answer: C
Rationale: Administering 4 oz of orange juice is the appropriate action for a client experiencing hypoglycemia due to diabetes mellitus. Orange juice contains simple sugars that can quickly raise blood glucose levels. Insulin (Choice A) would further lower blood sugar, worsening the condition. Glucagon (Choice B) is used in severe hypoglycemia when the client cannot take anything by mouth. Administering 1 L of water (Choice D) is not indicated in hypoglycemia treatment; the priority is to raise blood sugar levels. Therefore, the correct choice is to administer orange juice to address the low blood sugar in this situation.
4. A nurse is reviewing the plan of care for a client who is receiving oxygen therapy. Which of the following interventions should the nurse include to prevent complications?
- A. Check the client's oxygen saturation every 2 hours
- B. Provide humidified oxygen
- C. Instruct the client to perform deep breathing exercises
- D. Use an oxygen mask for delivery
Correct answer: B
Rationale: The correct answer is B: Provide humidified oxygen. Providing humidified oxygen helps prevent dryness and irritation of the respiratory tract during oxygen therapy. This intervention is crucial in preventing complications such as mucous membrane dryness and potential damage to the airways. Checking the client's oxygen saturation every 2 hours (choice A) is essential for monitoring the client's response to therapy but does not directly prevent complications. Instructing the client to perform deep breathing exercises (choice C) is beneficial for respiratory function but does not directly address preventing complications related to oxygen therapy. Using an oxygen mask for delivery (choice D) is a common method of administering oxygen but does not specifically focus on preventing complications like dryness and irritation.
5. What are the key signs of infection after surgery?
- A. Redness
- B. Swelling
- C. Fever
- D. All of the above
Correct answer: D
Rationale: After surgery, key signs of infection include redness, swelling, and fever. Redness and swelling can indicate inflammation at the surgical site, while fever is a systemic response to infection. Choosing 'All of the above' (Option D) is the correct answer because all three signs are commonly associated with post-surgical infections. Options A, B, and C are incorrect as each of them individually can be a sign of infection, but considering all three together provides a more comprehensive assessment for post-operative infection.
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