a nurse is assessing a client who is 2 hours postoperative following a gastrectomy which of the following findings should the nurse report to the prov
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Nursing Elites

ATI RN

ATI RN Exit Exam

1. A nurse is assessing a client who is 2 hours postoperative following a gastrectomy. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a serious condition post-gastrectomy. Hypoxemia can lead to inadequate oxygen delivery to tissues, potentially causing complications like organ dysfunction or failure. This finding requires immediate attention to prevent further deterioration. The heart rate, respiratory rate, and temperature are within normal ranges for a client post-gastrectomy, so they do not require immediate reporting to the provider.

2. A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.

3. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action the nurse should take when caring for a client experiencing acute alcohol withdrawal is to administer lorazepam as prescribed. Lorazepam is a benzodiazepine used to prevent seizures and manage agitation in clients undergoing alcohol withdrawal. Administering haloperidol (Choice A) is not recommended in alcohol withdrawal as it may lower the seizure threshold. Keeping the client in a supine position (Choice B) is not specifically indicated in managing alcohol withdrawal. Encouraging the client to drink fluids with meals (Choice D) is important for hydration but does not address the acute symptoms of alcohol withdrawal.

4. A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?

Correct answer: B

Rationale: In schizophrenia, clients often display an inability to identify common objects due to cognitive impairment. This is known as associative agnosia, where individuals struggle to recognize familiar objects, faces, or sounds. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head trauma or drug overdose. Poor problem-solving ability may be seen in various mental health disorders but is not specific to schizophrenia. Preoccupation with somatic disturbances is more commonly seen in somatic symptom disorders or somatic delusions, not a typical finding in schizophrenia.

5. A client has a new ileostomy. Which of the following actions should the nurse take?

Correct answer: C

Rationale: Changing the entire pouching system weekly is essential for maintaining skin integrity and preventing infection. Option A is incorrect as applying a skin barrier should be done during the pouch change, not separately. Option B is incorrect as ileostomy pouches should be emptied when they are one-third to one-half full to prevent leakage. Option D is incorrect because cleansing the peristomal skin with alcohol can be too harsh and may cause skin irritation.

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