a nurse is caring for a client who is 2 hours postoperative following a cholecystectomy which of the following actions should the nurse take to preven

ATI RN

ATI Exit Exam 2023 Quizlet

1. A nurse is caring for a client who is 2 hours postoperative following a cholecystectomy. Which of the following actions should the nurse take to prevent postoperative complications?

A. Instruct the client to perform deep breathing and coughing exercises.
B. Have the client wear sequential compression devices (SCDs).
C. Place the client in a supine position with the head of the bed flat.
D. Encourage the client to ambulate every 2 hours.

Correct answer: B

Rationale: The correct answer is B: Have the client wear sequential compression devices (SCDs). Following a cholecystectomy, the client is at risk for venous thromboembolism (VTE) due to reduced mobility and surgical stress. SCDs help prevent VTE by promoting venous return and reducing the risk of blood clots. Choices A, C, and D are incorrect. While deep breathing and coughing exercises are essential postoperatively, SCDs take precedence in preventing VTE. Placing the client in a supine position with the head of the bed flat can increase the risk of respiratory complications. Encouraging ambulation is important, but SCDs are a higher priority in this situation to prevent VTE.

2. A nurse is assessing a client who has a history of urinary incontinence. Which of the following findings should the nurse report to the provider?

A. Urine output of 50 mL in 2 hours
B. Presence of an indwelling urinary catheter
C. Frequent urination at night
D. Dark-colored urine

Correct answer: D

Rationale: The correct answer is D, dark-colored urine. Dark-colored urine can indicate various issues such as dehydration, liver problems, or blood in the urine, which could be concerning and require further evaluation by the provider. Choices A, B, and C are not necessarily findings that would need immediate reporting to the provider. A urine output of 50 mL in 2 hours might be low but could be influenced by various factors and might not always require immediate action. The presence of an indwelling urinary catheter is a known history and not a new finding. Frequent urination at night could be a symptom related to various conditions but may not be an urgent concern unless accompanied by other significant symptoms.

3. Which lab value is essential for a patient receiving warfarin therapy?

A. Monitor INR
B. Monitor sodium levels
C. Monitor potassium levels
D. Monitor platelet count

Correct answer: A

Rationale: The correct answer is to monitor the INR (International Normalized Ratio) for a patient receiving warfarin therapy. INR monitoring is crucial to assess the effectiveness of warfarin in preventing blood clots while minimizing the risk of bleeding. Monitoring sodium levels (choice B), potassium levels (choice C), or platelet count (choice D) is not specifically essential for patients on warfarin therapy and does not provide direct information on the drug's anticoagulant effects.

4. Which lab value is critical for monitoring warfarin therapy?

A. Monitor INR
B. Monitor platelet count
C. Monitor sodium levels
D. Monitor calcium levels

Correct answer: A

Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial for monitoring warfarin therapy as it helps assess the therapeutic effectiveness and bleeding risks associated with the medication. INR measures the clotting tendency of blood, which is essential in determining the appropriate dosage of warfarin. Monitoring platelet count (B), sodium levels (C), or calcium levels (D) is not primarily used for assessing warfarin therapy. Platelet count is more relevant in assessing bleeding disorders, while sodium and calcium levels are typically monitored for different medical conditions unrelated to warfarin therapy.

5. A nurse is caring for a client who is 1 day postoperative following abdominal surgery. The nurse should suspect that the client has developed an infection based on which of the following findings?

A. Blood pressure of 110/70 mm Hg
B. Temperature of 38.5°C (101.3°F)
C. Heart rate of 92/min
D. Drainage at the surgical site

Correct answer: B

Rationale: An elevated temperature of 38.5°C (101.3°F) is indicative of infection postoperatively. Fever is a common sign of infection, and temperatures above the normal range should raise suspicion. The other vital signs (blood pressure, heart rate) may be within an acceptable range, and some drainage at the surgical site can be expected postoperatively. However, the elevated temperature is a more specific indicator of a potential infection that requires immediate attention.