a nurse is assessing a client who is 48 hr postoperative following abdominal surgery which of the following findings should the nurse report to the pr
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Nursing Elites

ATI RN

ATI Exit Exam 2024

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

Correct answer: B

Rationale: Sanguineous drainage from the surgical site 48 hours after surgery could indicate a complication such as hemorrhage or infection and should be reported. Sanguineous drainage is typically seen in the early postoperative period due to the presence of blood. Serous drainage, on the other hand, is normal in the later stages of wound healing. A heart rate of 80/min is within the normal range for an adult. A temperature of 37.5°C (99.5°F) is slightly elevated but not a concerning finding in the absence of other symptoms.

2. A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the healthcare professional take first?

Correct answer: D

Rationale: Verifying the client's tube placement is the priority before administering any enteral feeding. This step ensures that the tube is correctly positioned in the stomach or intestines, minimizing the risk of complications such as aspiration. Checking the residual volume, elevating the head of the bed, and flushing the tube are important steps but should occur after confirming the tube placement to ensure the feeding is delivered safely and effectively.

3. A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborns. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?

Correct answer: C

Rationale: Respecting cultural dietary preferences enhances patient-centered care.

4. A nurse is teaching a client who has hypertension about managing blood pressure. Which of the following statements should the nurse make?

Correct answer: C

Rationale: The correct statement is C: 'Exercise for at least 30 minutes most days of the week.' Regular exercise is essential in managing blood pressure as it helps improve cardiovascular health. Choice A is incorrect as increasing red meat intake can be detrimental due to its high saturated fat content, which can negatively impact blood pressure. Choice B is not directly related to managing blood pressure unless the medication interacts negatively with alcohol. Choice D, limiting fluid intake to 3 liters per day, is not a general recommendation for managing blood pressure unless specifically advised by a healthcare provider.

5. A client has Clostridium difficile infection. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile infection is to place the client on contact precautions. This helps prevent the spread of the infection to other clients. Washing hands with an alcohol-based hand rub is important for infection control but is not specific to preventing the spread of Clostridium difficile. Wearing a mask may be necessary for airborne precautions but is not the priority for Clostridium difficile infection. Double-bagging linens is not a standard practice for preventing the spread of Clostridium difficile.

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