a nurse is caring for a client who is 1 day postoperative following abdominal surgery which of the following findings should the nurse report to the p

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

A. Serosanguineous drainage on the surgical dressing.
B. Heart rate of 88/min.
C. Blood pressure of 118/76 mm Hg.
D. Temperature of 38.8°C (101.8°F).

Correct answer: D

Rationale: A temperature of 38.8°C (101.8°F) is above the normal range and may indicate infection, which should be reported. Elevated temperature postoperatively can be a sign of infection, especially in the early postoperative period. Serosanguineous drainage on the surgical dressing is expected in the early postoperative period. A heart rate of 88/min and a blood pressure of 118/76 mm Hg are within normal ranges and do not necessarily indicate a complication postoperatively.

2. A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an incident report?

A. A client receives his antibiotics 2 hours late.
B. A client vomits within 20 minutes of taking his morning medications.
C. A client requests his statin to be administered at 2100.
D. A client asks for pain medication 1 hour early.

Correct answer: A

Rationale: The correct answer is A. When a client receives antibiotics 2 hours late, it constitutes a medication error, requiring the completion of an incident report. Choice B, a client vomiting within 20 minutes of taking medications, does not necessarily require an incident report unless it is suspected to be related to a medication error. Choice C, a client requesting a statin at a specific time, and choice D, a client asking for pain medication an hour early, are not incidents that mandate the completion of an incident report unless there are specific circumstances indicating otherwise.

3. A client with a new diagnosis of hypertension is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

A. I will check my blood pressure at least once a week.
B. I will avoid eating foods high in potassium.
C. I should exercise for 30 minutes at least 5 days a week.
D. I will take my medication only when I feel dizzy.

Correct answer: C

Rationale: The correct answer is C. Regular exercise is an essential component in managing hypertension. Exercising for at least 30 minutes a day, at least 5 days a week, can help control blood pressure. Checking blood pressure regularly (choice A) is important, but not as indicative of understanding the teaching as the commitment to regular exercise. Avoiding foods high in potassium (choice B) is not a typical recommendation for managing hypertension. Taking medication only when feeling dizzy (choice D) is incorrect and potentially dangerous; medications should be taken as prescribed by the healthcare provider.

4. What is the most important intervention for a patient with suspected DVT?

A. Administer anticoagulants
B. Monitor oxygen levels
C. Apply compression stockings
D. Encourage ambulation

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Administering anticoagulants is crucial in the management of deep vein thrombosis (DVT) as it helps prevent the clot from growing larger or dislodging, potentially causing a life-threatening pulmonary embolism. While monitoring oxygen levels, applying compression stockings, and encouraging ambulation are important aspects of DVT management, administering anticoagulants is the most critical intervention to prevent further complications.

5. What is the most important nursing assessment post-surgery?

A. Monitor vital signs
B. Monitor blood pressure
C. Monitor the surgical site
D. Monitor the incision site

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs encompass various parameters like blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of complications such as hemorrhage, infection, or shock. While monitoring the surgical site and incision site are also essential post-surgery, monitoring vital signs takes precedence as it provides a broader assessment of the patient's overall condition. Monitoring blood pressure is part of vital sign assessment and is not the most comprehensive assessment post-surgery.