a nurse is caring for a client who is 1 day postoperative following abdominal surgery which of the following actions should the nurse take to prevent
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A client is 1 day postoperative following abdominal surgery. Which of the following actions should the nurse take to prevent respiratory complications?

Correct answer: B

Rationale: Encouraging the use of an incentive spirometer is crucial for preventing respiratory complications postoperatively, such as atelectasis. Instructing the client to avoid deep breathing exercises (choice A) is incorrect as deep breathing exercises help prevent respiratory complications. Assisting with ambulation every 2 hours (choice C) is important for preventing other postoperative complications but not specifically respiratory ones. Applying sequential compression devices (SCDs) (choice D) is beneficial for preventing deep vein thrombosis but not directly related to respiratory complications.

2. A charge nurse is teaching a group of nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?

Correct answer: D

Rationale: The correct use of restraints is crucial to ensure patient safety. Keeping the side rails of a toddler's crib elevated is a safe practice as it prevents falls and provides a level of protection without directly restraining the child. Placing a belt restraint on a child with seizures (Choice A) is inappropriate as it may restrict movement and cause harm during a seizure. Securing wrist restraints to bed rails for an adolescent (Choice B) is not recommended as it can lead to injuries and compromise circulation. Applying elbow immobilizers to an infant with a cleft lip injury (Choice C) is also incorrect as it does not address the issue of restraint and is not a standard practice in this situation.

3. What is the primary nursing action for a patient with confusion post-surgery?

Correct answer: A

Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.

4. A nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D. Urine output less than 30 mL/hr indicates decreased kidney perfusion, which is a serious complication of preeclampsia. Reporting this finding is crucial for prompt intervention. Choices A, B, and C are not the priority as fetal heart rate of 110/min, 1+ pitting edema, and blood pressure of 138/80 mm Hg are within normal limits for a client with preeclampsia at 38 weeks of gestation.

5. When administering an incorrect dose of medication, which facts related to the incident report should the nurse document in the client's medical record?

Correct answer: A

Rationale: The nurse should document the time the medication was given in the client's medical record when administering an incorrect dose. This information is crucial for tracking the sequence of events leading to the error. Choice B, the client's response to the medication, is important for monitoring the client's condition post-administration but may not be directly linked to the incident report. Choice C, documenting the dose that was administered, is relevant but does not provide insights into the timing of events. Choice D, detailing the reason for the error, should be included in the incident report but may not need to be documented in the client's medical record.

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