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. What are the nursing interventions for a patient with pneumonia?

Correct answer: B

Rationale: The correct nursing interventions for a patient with pneumonia include monitoring lung sounds and respiratory rate to assess the effectiveness of treatment and the patient's respiratory status. Providing fluids and rest (Choice A) can be supportive measures but are not specific nursing interventions for pneumonia. Encouraging coughing and deep breathing exercises (Choice C) can be helpful for airway clearance but may not be appropriate for all patients with pneumonia. Administering antibiotics and providing oxygen therapy (Choice D) are medical interventions rather than nursing interventions.

3. A patient is on contact precautions for an infection. What is the most important action for the nurse to take?

Correct answer: A

Rationale: The most important action for the nurse to take when caring for a patient on contact precautions is to wear gloves when entering the patient's room. This is crucial in preventing the spread of infection from the patient to the healthcare provider and vice versa. Placing the patient in a private room may be necessary for airborne precautions but is not specifically related to contact precautions. Using a dedicated blood pressure cuff for the patient is important for preventing cross-contamination but is not the most critical action. Disposing of equipment in a biohazard bag is a standard procedure but is not the most important action in this scenario.

4. A nurse is preparing to administer morphine sulfate to a client. What should the nurse assess before administration?

Correct answer: B

Rationale: Correct answer: Before administering morphine sulfate, the nurse should monitor for respiratory depression as it is a significant side effect of this medication. Assessing for pain relief (Choice A) is important but not a pre-administration assessment. Checking the infusion site for complications (Choice C) is relevant for IV medications, not specifically for morphine sulfate. Increasing the dosage if the client reports more pain (Choice D) is not appropriate without further assessment and medical orders.

5. 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.

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