a nurse is assessing a client who is 2 days postoperative following abdominal surgery which of the following findings should the nurse report to the p
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Nursing Elites

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ATI RN Exit Exam Test Bank

1. A nurse is assessing a client who is 2 days postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C because a urine output of 30 mL/hr indicates oliguria, which can be a sign of dehydration or kidney impairment postoperatively. This finding should be reported to the provider for further evaluation. Choices A, B, and D are within normal parameters for a client who is 2 days postoperative following abdominal surgery and do not raise immediate concerns. Serosanguineous drainage on the dressing is an expected finding in the early postoperative period, a heart rate of 88/min is within the normal range, and a blood pressure of 110/70 mm Hg is also within normal limits.

2. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

Correct answer: A

Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.

3. A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D because a blood glucose level of 120 mg/dL falls within the normal range. A low serum albumin level, as mentioned in choice B, should be reported as it may indicate malnutrition. Choices A and C are within normal ranges and would not typically require immediate reporting.

4. A nurse is preparing to administer an immunization to a 6-month-old infant. Which of the following actions should the nurse take to reduce pain at the injection site?

Correct answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

5. A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?

Correct answer: D

Rationale: The correct answer is D: Understanding of infant care. When assessing a pregnant adolescent, the priority is to ensure that she has the necessary knowledge and skills to care for her newborn. This assessment is crucial in promoting the health and well-being of both the adolescent mother and her baby. Option A, social relationships with peers, though important, is not the priority during this assessment. Option B, plans for attending school while pregnant, is also important but does not take precedence over ensuring the adolescent's understanding of infant care. Option C, eligibility for Medicaid, is important for accessing healthcare services but is not the priority assessment in this scenario.

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