what are the signs of infection that a nurse should monitor for in a postoperative patient
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. What are the signs of infection that should be monitored in a postoperative patient?

Correct answer: D

Rationale: The correct answer is D: 'Redness, swelling, and warmth at the surgical site.' These are specific signs of infection at the surgical site that a nurse should monitor for in a postoperative patient. While fever, chills, and increased pain can also indicate infection, the most direct signs are redness, swelling, and warmth at the surgical site. Therefore, 'D' is the best choice as it directly relates to the site of the surgery and is crucial to monitor for potential postoperative infections.

2. A healthcare professional is giving a change-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is the priority for the healthcare professional to provide?

Correct answer: C

Rationale: The correct answer is C: 'Breath sounds.' When providing a change-of-shift report for a client with pneumonia, the priority information to communicate is the assessment of breath sounds. Monitoring breath sounds is crucial in assessing respiratory status and the effectiveness of treatments in pneumonia. Option A, recent chest x-ray results, may be important but does not provide real-time information on the client's current status. Option B, medication history, is relevant but not as immediate as assessing breath sounds. Option D, lab results, can provide valuable information but may not be as urgent as monitoring the client's respiratory status through breath sounds.

3. A client with hyperthyroidism is prescribed propranolol. Which finding indicates that the propranolol is effective?

Correct answer: B

Rationale: The correct answer is B because a decrease in blood pressure is an expected outcome when propranolol, a beta-blocker, is effectively managing hyperthyroidism. Propranolol helps control symptoms such as tachycardia and hypertension associated with hyperthyroidism. Choices A, C, and D are incorrect because weight gain, increased energy, and an increased respiratory rate are not direct indicators of propranolol's effectiveness in treating hyperthyroidism.

4. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

Correct answer: D

Rationale: TENS is a portable treatment that can be done at home, so the client should not expect to remain in the hospital for this treatment.

5. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Correct answer: A

Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.

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