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. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

Correct answer: A

Rationale: The correct answer is to secure a clean container before sputum collection. This is essential to prevent contamination of the specimen, ensuring accurate test results and avoiding the introduction of external particles or bacteria. Choice B is incorrect because discarding the container if the outside becomes dirty is not necessary; the cleanliness of the inside is crucial. Choice C is incorrect as rinsing the client's mouth with Listerine before collection may introduce unwanted substances that can affect the test results. Choice D is incorrect as the amount of sputum required can vary depending on the test, and specifying a specific amount without medical guidance is not appropriate.

3. Which of the following statements does NOT apply to a nursing plan of care?

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate needs. Choice C is also accurate as nursing plans of care need to be continually evaluated and updated to ensure they are effective. Choice D is incorrect as nursing plans of care can contain long-range goals to provide a roadmap for the patient's overall care and recovery.

4. Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task 'Educate soldiers in the history and traditions of the service'?

Correct answer: B

Rationale: The appropriate category for the task 'Educate soldiers in the history and traditions of the service' is 'Personal/professional development.' This category involves educating individuals in various aspects, including history and traditions, to enhance their overall growth and knowledge. Choices A, C, and D are incorrect because 'Accountability' focuses on responsibility and answerability, 'Individual training' refers to specific skill development, and 'Military appearance/physical condition' pertains to physical fitness and presentation, none of which directly align with educating soldiers in history and traditions.

5. Listed below are five categories that identify the responsibilities of the practical nurse manager in personnel management. Which of these categories is most appropriate for the task of 'Educate personnel on UCMJ'?

Correct answer: B

Rationale: The correct answer is 'B: Personal/professional development.' Educating personnel on the Uniform Code of Military Justice (UCMJ) falls under the realm of personal/professional development, as it aims to enhance the knowledge and skills of individuals regarding military laws and regulations. Choice A, 'Accountability,' focuses more on responsibility and answerability rather than education. Choice C, 'Individual training,' is more specific to skill development and job-related learning rather than legal education. Choice D, 'Military appearance/physical condition,' pertains to maintaining physical standards and appearance, which is unrelated to educating personnel on UCMJ.

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