a nurse is assessing a client who is 2 hours postoperative following a gastrectomy which of the following findings should the nurse report to the prov

ATI RN

ATI RN Exit Exam

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

A. Heart rate of 94/min
B. Oxygen saturation of 88%
C. Respiratory rate of 18/min
D. Temperature of 37.6°C (99.7°F)

Correct answer: B

Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a serious condition post-gastrectomy. Hypoxemia can lead to inadequate oxygen delivery to tissues, potentially causing complications like organ dysfunction or failure. This finding requires immediate attention to prevent further deterioration. The heart rate, respiratory rate, and temperature are within normal ranges for a client post-gastrectomy, so they do not require immediate reporting to the provider.

2. Which medication is used to reverse the effects of opioid overdose?

A. Naloxone
B. Epinephrine
C. Atropine
D. Lidocaine

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is specifically used to reverse the effects of opioid overdose by binding to opioid receptors and blocking the effects of opioids. Epinephrine is mainly used to treat severe allergic reactions, Atropine is used for certain types of heart conditions and to reduce salivation or respiratory secretions, and Lidocaine is a local anesthetic used for numbing purposes. Therefore, choices B, C, and D are incorrect in the context of reversing opioid overdose.

3. A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?

A. Flush the tube with 30 mL of sterile water before each feeding.
B. Check for gastric residuals every 4 hours.
C. Elevate the head of the bed to 45 degrees during feedings.
D. Place the client in the left lateral position during feedings.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.

4. What should be monitored when administering opioids to a patient?

A. Monitor blood pressure
B. Monitor respiratory rate
C. Monitor heart rate
D. Monitor oxygen saturation

Correct answer: B

Rationale: When administering opioids, monitoring the respiratory rate is crucial to detect any signs of respiratory depression, which is a serious side effect of opioid use. Monitoring blood pressure, heart rate, and oxygen saturation are important parameters to assess a patient's overall condition, but they are not the primary focus when administering opioids.

5. A nurse is caring for a client who has a prescription for clozapine. Which of the following laboratory values should the nurse monitor?

A. Monitor blood glucose levels
B. Monitor WBC count
C. Monitor platelet count
D. Monitor hemoglobin levels

Correct answer: B

Rationale: The correct answer is to monitor the WBC count. Clozapine can cause agranulocytosis, a severe decrease in WBC count, which can increase the risk of infection. Monitoring the WBC count is essential to detect this potentially life-threatening condition early. Monitoring blood glucose levels (Choice A) is not directly related to clozapine use. Platelet count (Choice C) and hemoglobin levels (Choice D) are not typically affected by clozapine and are not the priority for monitoring in this case.