a nurse is assessing a client who is 48 hours postoperative following abdominal surgery which of the following findings should the nurse report to the a nurse is assessing a client who is 48 hours postoperative following abdominal surgery which of the following findings should the nurse report to the
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ATI Exit Exam

1. A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D. An elevated WBC count can indicate a potential infection, especially in a postoperative client. This finding should be reported to the provider for further evaluation and management. Choices A, B, and C are common occurrences in postoperative clients and may not necessarily indicate a severe issue. Serosanguineous drainage on the surgical dressing is a normal finding in the immediate postoperative period. A temperature of 37.8°C (100°F) can be a mild fever, which is common postoperatively due to the body's response to tissue injury. Urine output of 75 mL in the past 4 hours may be within normal limits for a postoperative client, especially if they are still recovering from anesthesia.

2. A healthcare provider is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

Correct answer: A client who has a diagnosis of preeclampsia reports epigastric pain and an unresolved headache

Rationale: The correct answer is a client who has a diagnosis of preeclampsia reporting epigastric pain and an unresolved headache. These symptoms indicate severe preeclampsia, which requires immediate medical attention due to the potential risks of complications such as HELLP syndrome or eclampsia. The other options describe concerning situations but do not represent immediate life-threatening conditions like those seen in severe preeclampsia.

3. A nurse is caring for a client who is at risk for developing a deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?

Correct answer: D

Rationale: The correct answer is D: Apply sequential compression devices to the client's legs. Sequential compression devices help prevent venous stasis and reduce the risk of DVT by promoting blood flow in the legs. Massaging the client's legs every 2 hours (choice A) may dislodge a clot if present, leading to a higher risk of embolism. Instructing the client to sit with the legs crossed (choice B) can impede blood flow and increase the risk of DVT. Administering prophylactic antibiotics (choice C) is not indicated for preventing DVT, as antibiotics are used to treat infections caused by bacteria, not to prevent blood clots.

4. Which therapy style requires the therapist to actively confront a client's irrational beliefs?

Correct answer: D

Rationale: The correct answer is D, REBT (Rational Emotive Behavior Therapy). REBT involves actively confronting and changing irrational beliefs. Choice A, Person-centered therapy, is focused on providing a supportive and empathetic environment rather than confronting irrational beliefs. Choice B, Psychodynamic psychotherapy, emphasizes exploring unconscious processes and early life experiences rather than direct confrontation of irrational beliefs. Choice C, Electroconvulsive therapy, is a biological treatment for severe depression and other mental illnesses, not a therapy style that involves confronting irrational beliefs.

5. A nurse is providing discharge instructions to a client following a gastrectomy. Which of the following strategies should the nurse include in the teaching?

Correct answer: D

Rationale: The correct strategy to include in the teaching after a gastrectomy is to avoid drinking liquids with meals. This helps prevent dumping syndrome, a condition characterized by rapid emptying of undigested food and fluids from the stomach into the small intestine. Choices A, B, and C are incorrect. Drinking fluids between meals is appropriate to maintain hydration, eating three large meals can exacerbate dumping syndrome, and lying down after meals is not recommended as it can increase the risk of reflux.

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