how should a nurse assess for signs of infection in a post surgical patient
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. How should signs of infection in a post-surgical patient be assessed?

Correct answer: A

Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.

2. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following foods should the nurse instruct the client to avoid?

Correct answer: C

Rationale: Bananas are high in potassium, which should be avoided by clients with chronic kidney disease to prevent hyperkalemia. Apples, white bread, and grapes do not have high potassium levels and are generally acceptable for clients with chronic kidney disease unless they have other specific dietary restrictions.

3. A nurse is providing discharge instructions for a client who has osteoporosis. Which of the following instructions should the nurse include to prevent injury?

Correct answer: A

Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises are crucial for preventing bone density loss in clients with osteoporosis. These exercises help strengthen bones and reduce the risk of fractures. Option B, avoiding crossing the legs beyond the midline, is not directly related to preventing injury in osteoporosis. Option C, avoiding sitting in one position for prolonged periods, is important for preventing pressure ulcers but does not specifically address preventing injury in osteoporosis. Option D, splinting the affected area, is not a standard recommendation for preventing injury in osteoporosis.

4. A nurse is caring for a client who has anemia and a hemoglobin level of 8 g/dL. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Tachypnea. Anemia leads to decreased oxygen-carrying capacity due to low hemoglobin levels, prompting the body to increase respiratory rate to enhance oxygen uptake. Jaundice (choice A) is associated with liver issues, not anemia. Bradycardia (choice B) and Hypertension (choice D) are not typically expected findings in clients with anemia; instead, tachycardia may occur as the body compensates for the decreased oxygen delivery.

5. A nurse is caring for a client who is experiencing dysphagia. Which of the following interventions should the nurse implement?

Correct answer: A

Rationale: The correct intervention for a client with dysphagia is to administer thickened liquids. Thickened liquids help prevent aspiration, which is a common risk for clients with swallowing difficulties. Providing small bites of food (choice B) can help, but the priority is to modify the liquid consistency. Encouraging the client to eat quickly (choice C) is not recommended as it may increase the risk of aspiration and fatigue. Having the client lie supine after meals (choice D) can actually increase the risk of aspiration, especially in clients with dysphagia.

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