the nurse is caring for the client recovering from intestinal surgery which assessment finding would require immediate intervention
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 4

1. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

Correct answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. This finding suggests a systemic response to infection, which can be life-threatening if not promptly addressed. Options A, B, and C are common postoperative findings and may not necessarily require immediate intervention unless accompanied by other concerning signs or symptoms.

2. Which lipoprotein carries cholesterol from tissues to the liver for excretion?

Correct answer: D

Rationale: The correct answer is D, High-density lipoprotein (HDL). HDL is known as 'good' cholesterol because it helps transport excess cholesterol from tissues back to the liver for removal from the body. Very low-density lipoprotein (VLDL) (choice A) and intermediate-density lipoprotein (choice B) are involved in transporting triglycerides. Low-density lipoprotein (LDL) (choice C) is known as 'bad' cholesterol as it can deposit cholesterol in the walls of arteries.

3. Why may patients with hiatal hernia develop anemia?

Correct answer: B

Rationale: The correct answer is B: Gastritis may cause bleeding. In patients with hiatal hernia, gastritis can lead to gastrointestinal bleeding, resulting in anemia due to blood loss. Choice A is incorrect because hiatal hernia does not directly affect iron absorption. Choice C is incorrect as iron stores turning over more quickly is not a typical reason for anemia in hiatal hernia patients. Choice D is incorrect as an aversion to iron-rich foods does not directly cause anemia in this context.

4. The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?

Correct answer: B

Rationale: The correct answer is B. Decreasing the intake of flatus-forming foods can help reduce symptoms of bloating and discomfort in IBS. This intervention focuses on dietary modifications that can positively impact the client's condition. Instructing the client to avoid drinking fluids with meals (choice A) may not directly address the underlying cause of IBS symptoms. Teaching perianal care (choice C) is important for hygiene but does not directly address IBS symptoms. Encouraging the client to see a psychologist (choice D) may be beneficial for managing stress or anxiety associated with IBS but does not directly target symptom reduction through dietary changes.

5. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?

Correct answer: B

Rationale: The correct answer is B: Decreased urine output. When vegetative lesions from the mitral valve embolize, they can block blood flow to the kidneys, leading to renal infarction. This can result in decreased urine output. Choices A, C, and D are incorrect. Pulmonary embolism involves a blockage of an artery in the lungs, not directly related to embolization from the mitral valve. Hemoptysis is the coughing up of blood from the respiratory tract, which is not a direct consequence of embolization from the mitral valve. Deep vein thrombosis is the formation of a blood clot in a deep vein, unrelated to embolization from the mitral valve.

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