a nurse is caring for a client who is 1 hr postoperative following rhinoplasty which of the following manifestations requires immediate action by the
Logo

Nursing Elites

ATI LPN

ATI NCLEX PN Predictor Test

1. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?

Correct answer: A

Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.

2. What are the key factors in assessing a patient's fall risk?

Correct answer: A

Rationale: The correct answer is A. Assessing the patient's age and mobility are key factors in determining fall risk. Age can affect balance and reaction time, while mobility influences the patient's stability. Choices B, C, and D are important considerations in assessing a patient's fall risk as well, but age and mobility play a more direct role in determining the patient's susceptibility to falls.

3. A nurse is caring for a client who is 2 hours postoperative following a colon resection. Which of the following assessments is the nurse's priority?

Correct answer: D

Rationale: The correct answer is D: Oxygen saturation. The priority assessment in this situation is oxygen saturation because postoperative clients are at risk for respiratory complications, such as hypoxia due to factors like anesthesia effects, impaired lung function, or pain interfering with deep breathing. Monitoring oxygen saturation is crucial to detect any respiratory compromise early. Capillary refill, bowel sounds, and temperature are important assessments but are not the priority in this immediate postoperative period.

4. A client who has undergone vein ligation and stripping to treat varicose veins should be instructed to do which of the following activities during discharge teaching?

Correct answer: B

Rationale: The correct answer is B: 'Walk for 1-2 hours each day.' After vein ligation and stripping, walking helps promote circulation and aids in the recovery process. Option A is incorrect as remaining sedentary for 2-3 days can lead to decreased circulation and potentially increase the risk of complications. Option C is incorrect because compression stockings should typically be worn during the day to support circulation. Option D is incorrect as elevating the legs while sitting is beneficial, but walking is more effective in promoting circulation and recovery in this case.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take to prevent infection?

Correct answer: B

Rationale: The correct answer is B. Changing the TPN tubing every 24 hours is crucial in preventing infection by reducing the risk of bacterial contamination. Monitoring electrolyte levels (choice A) is essential but not directly related to preventing TPN-related infections. Monitoring blood glucose levels (choice C) is important for clients receiving TPN, but it is more related to glycemic control than infection prevention. Administering insulin as prescribed (choice D) is necessary for clients with diabetes but is not directly linked to preventing TPN-related infections.

Similar Questions

What should the nurse do first when a client with a tracheostomy exhibits respiratory distress?
A client is prescribed simvastatin. Which instruction should the nurse provide during teaching?
What are the complications of untreated hyperglycemia?
A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?
A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses