a charge nurse is recommending postpartum client discharge following a local disaster which of the following should the nurse recommend for discharge

ATI RN

ATI Fundamentals Proctored Exam

1. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?

A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration

Correct answer: D

Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.

2. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

A. Less than 30 ml/hour
B. 64 ml in 2 hours
C. 90 ml in 3 hours
D. 125 ml in 4 hours

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

3. During a seizure, what is the primary intervention?

A. Protect the patient from injury
B. Insert an airway
C. Elevate the head of the bed
D. Withdraw all pain medications

Correct answer: A

Rationale: The primary intervention during a seizure is to protect the patient from injury. This involves creating a safe environment by moving harmful objects away, cushioning the head, and staying with the patient until the seizure ends. Inserting an airway is only necessary if the patient's airway is obstructed, not routinely during a seizure. Elevating the head of the bed is not a priority during an active seizure as it won't affect the seizure's outcome. Withdrawing all pain medications is not a standard practice unless there are specific contraindications related to the seizure itself.

4. Which of the following principles of primary nursing has proven most satisfying to the patient and nurse?

A. Continuity of patient care promotes efficient and cost-effective nursing care.
B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

Correct answer: D

Rationale: The holistic approach, encompassing a therapeutic relationship, continuity, and efficient nursing care, is the most satisfying principle of primary nursing. This approach considers the patient as a whole, taking into account physical, emotional, social, and spiritual aspects, which enhances the nurse-patient relationship and promotes comprehensive care. It emphasizes individualized care delivery, continuity of care, and an integrated approach, leading to improved patient satisfaction and nurse fulfillment.

5. How many liters are equal to 1800 ml?

A. 1.8
B. 18000
C. 180
D. 2800

Correct answer: A

Rationale: To convert milliliters (ml) to liters, divide by 1000 since 1 liter is equal to 1000 ml. Therefore, 1800 ml is equal to 1800/1000 = 1.8 liters. Choice A (1.8) is correct. Choice B (18000) is incorrect as it equates to 18000 liters, not 1.8 liters. Choice C (180) is incorrect as it represents 180 liters, not 1.8 liters. Choice D (2800) is incorrect as it does not reflect the conversion of 1800 ml to liters.