a nurse is assessing a client who has just returned from surgery and is experiencing acute pain which of the following findings should the nurse expec
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Nursing Elites

ATI RN

ATI Exit Exam

1. A nurse is assessing a client who has just returned from surgery and is experiencing acute pain. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common response to acute pain due to increased sympathetic nervous system activity. Options A and B, Bradycardia and Hypotension, are unlikely findings in a client experiencing acute pain as pain usually triggers an increase in heart rate (tachycardia) and blood pressure. Option D, Hyperactive bowel sounds, is not typically associated with acute pain.

2. What is the most appropriate intervention for a patient with confusion post-surgery?

Correct answer: A

Rationale: Administering oxygen is the most appropriate intervention for a patient with confusion post-surgery because it helps alleviate confusion caused by potential hypoxia. In a post-surgical setting, confusion can be a sign of decreased oxygen levels in the blood due to various reasons such as respiratory depression, decreased lung function, or other complications. Administering oxygen can quickly address hypoxia, improving oxygenation to the brain and reducing confusion. Repositioning the patient, administering IV fluids, or performing a neurological assessment are not the primary interventions for confusion related to hypoxia post-surgery.

3. A client who is 2 hours postoperative following a kidney biopsy is being assessed by a nurse. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B. A hemoglobin level of 10 g/dL is below the normal range and should be reported following a kidney biopsy to check for bleeding. Decreased hemoglobin levels could indicate internal bleeding, which is a significant concern postoperatively. Choices A, C, and D are within normal limits and do not require immediate reporting. Urinary output of 30 mL/hr is also within the acceptable range for a postoperative client. A respiratory rate of 16/min and blood pressure of 110/70 mm Hg are both normal findings postoperatively.

4. What is the most concerning electrolyte imbalance for a patient receiving digoxin?

Correct answer: B

Rationale: The correct answer is Hypokalemia. Hypokalemia is the most concerning electrolyte imbalance for a patient receiving digoxin because it can increase the risk of digoxin toxicity. Low potassium levels can potentiate the effects of digoxin on the heart, leading to serious cardiac arrhythmias. Hyperkalemia (Choice A) is not typically associated with digoxin use. Hyponatremia (Choice C) and Hypercalcemia (Choice D) are not directly related to digoxin therapy and do not pose the same risk of toxicity.

5. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client?

Correct answer: D

Rationale: The correct answer is D. Food exchange lists from the American Diabetes Association are valuable resources for individuals with diabetes as they provide specific guidance on meal planning and portion control, which are crucial for managing blood sugar levels. Choice A is incorrect because personal blogs may not always provide accurate or evidence-based information. Choice B is incorrect as food label recommendations, while important, may not offer the structured guidance needed for meal planning in diabetes. Choice C is also incorrect as medication information is different from dietary guidance needed for diabetes management.

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