what are the priority nursing assessments for a patient who has just undergone major surgery
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. What are the priority nursing assessments for a patient who has just undergone major surgery?

Correct answer: B

Rationale: The correct answer is to monitor for signs of infection. After major surgery, one of the priority nursing assessments is to watch for signs of infection, such as increased temperature, redness, swelling, or drainage at the surgical site. While providing analgesia is important for pain management, monitoring for infection takes precedence as it can lead to severe complications if not detected early. Assessing the surgical site for bleeding is crucial but is usually more relevant immediately after surgery. Monitoring the patient's vital signs is essential, but the specific focus on infection assessment is crucial in the immediate postoperative period.

2. A client with asthma is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?

Correct answer: B

Rationale: Correct. Fluticasone, a corticosteroid medication commonly used to manage asthma, can lead to oral candidiasis due to its immunosuppressive effects. This fungal infection can manifest as white patches in the mouth and throat. Monitoring for signs of oral candidiasis is essential to initiate appropriate treatment. Polyuria (excessive urination) is not a common adverse effect of fluticasone. Hypertension and hypoglycemia are also not typically associated with this medication, making them incorrect choices.

3. A patient with COPD is admitted with shortness of breath and a productive cough. Which of the following interventions should the nurse implement first?

Correct answer: C

Rationale: Placing the patient in a high-Fowler’s position should be implemented first. This intervention helps improve lung expansion, making it easier for the patient to breathe. Elevating the head of the bed reduces the work of breathing and can alleviate symptoms of respiratory distress. Administering oxygen, encouraging coughing and deep breathing, and administering a bronchodilator are important interventions in the care of a patient with COPD, but positioning the patient for optimal lung expansion takes precedence in this scenario.

4. A nurse is caring for a female client who has osteoporosis and a new prescription for raloxifene. What should the nurse assess prior to initiating therapy?

Correct answer: A

Rationale: The correct answer is A: Pregnancy status. Raloxifene is a pregnancy category X drug, which means it can cause serious birth defects. Therefore, it is crucial for the nurse to assess the client's pregnancy status before initiating therapy. Choice B, bone density, while important in osteoporosis management, is not a specific concern related to initiating raloxifene therapy. Choice C, calcium levels, and choice D, blood pressure, are not directly related to the initiation of raloxifene therapy in a female client with osteoporosis.

5. Which intervention is essential when caring for a patient with a nasogastric (NG) tube?

Correct answer: B

Rationale: Checking the placement of the NG tube before each feeding is crucial to ensure it is correctly positioned and safe to use. Option A is incorrect as routine suctioning can lead to complications and should only be done as needed. Option C is not necessary unless there are specific instructions for flushing. Option D is incorrect as the NG tube should only be removed by healthcare professionals based on medical criteria, not solely based on the patient's comfort.

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