a nurse is assessing a client who is postoperative following a thyroidectomy which of the following findings should the nurse report to the provider
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

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

Correct answer: C

Rationale: The correct answer is C. A heart rate of 110/min is elevated and may indicate hypocalcemia, a potential complication following a thyroidectomy. Elevated heart rate can be a sign of hypocalcemia due to the close relationship between calcium levels and cardiac function. Option A, serum calcium level of 8 mg/dL, is within the normal range (8.5-10.5 mg/dL) and would not be a cause for concern post-thyroidectomy. Option B, urine output of 60 mL/hr, is within the normal range for urine output and not typically a priority finding post-thyroidectomy. Option D, a temperature of 37.5°C (99.5°F), is slightly elevated but not a critical finding post-thyroidectomy unless accompanied by other symptoms.

2. A healthcare provider is reviewing the laboratory report of a client with a prescription for digoxin. Which result requires withholding the medication?

Correct answer: D

Rationale: The correct answer is D. A low potassium level (3.1 mEq/L) can increase the risk of digoxin toxicity. Hypokalemia can potentiate the effects of digoxin on the heart, leading to serious dysrhythmias. Choices A, B, and C are within normal ranges and do not indicate a need to withhold digoxin.

3. A nurse is planning care for a client who has pneumonia. Which of the following actions should the nurse take to promote airway clearance?

Correct answer: C

Rationale: Encouraging the client to increase fluid intake is essential in promoting airway clearance for a client with pneumonia. Increased fluid intake helps thin secretions, making it easier for the client to clear their airways. Chest physiotherapy (Choice A) is more focused on mobilizing secretions and may not be suitable for all clients with pneumonia. Suctioning (Choice B) is indicated for clients who have excessive secretions that they cannot manage effectively themselves. Administering oxygen via nasal cannula (Choice D) is important for clients with pneumonia to maintain adequate oxygenation, but it does not directly promote airway clearance.

4. A nurse is assessing a newborn who is 1-day old and receiving phototherapy for jaundice. Which action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the infant's head covered with a cap. This helps regulate the newborn's body temperature during phototherapy. Option A, feeding the infant glucose water every 2 hours, is incorrect because it is not a standard intervention for newborns receiving phototherapy. Option B, ensuring the newborn wears a diaper, may be necessary for hygiene but is not directly related to phototherapy. Option D, applying lotion to the newborn every 4 hours, is unnecessary and not indicated for managing jaundice or phototherapy.

5. A client is receiving intermittent enteral tube feedings and is experiencing dumping syndrome. Which of the following actions should the nurse take?

Correct answer: C

Rationale: Dumping syndrome is a condition that occurs when food moves too quickly from the stomach into the small intestine. Symptoms can include abdominal cramping, diarrhea, and sweating. To manage dumping syndrome in a client receiving enteral tube feedings, the nurse should decrease the rate of the feedings. This intervention helps slow down the movement of food through the gastrointestinal tract, reducing the symptoms. Administering a refrigerated feeding (choice A) or increasing the amount of water used to flush the tubing (choice B) are not appropriate actions for addressing dumping syndrome. Instructing the client to move onto their right side (choice D) is not a relevant intervention for managing dumping syndrome in this scenario.

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