a nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy what should the nurse report
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?

Correct answer: A

Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.

2. What is the best method to monitor fluid balance in a patient receiving diuretics?

Correct answer: A

Rationale: The best method to monitor fluid balance in a patient receiving diuretics is to monitor daily weight. Daily weighing is a precise way to assess changes in fluid status as it reflects variations in total body water. Monitoring intake and output (choice B) is also important but may not provide as accurate a measurement as daily weight. Monitoring blood pressure (choice C) is essential but does not directly measure fluid balance. Monitoring edema (choice D) is helpful to assess fluid status visually but may not be as sensitive as daily weight measurements in detecting subtle changes in fluid balance.

3. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: The correct first action for the nurse to take when preparing to administer a unit of packed RBCs is to check the client's identification band. This step is crucial to ensure that the correct blood is administered to the right client, preventing any errors or adverse reactions. Verifying the provider's prescription, priming the IV tubing, and obtaining the client's vital signs are important steps in the process but should follow the initial identification check to prioritize patient safety.

4. A nurse is providing discharge teaching to a client who has hypertension about monitoring blood pressure at home. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before measuring their blood pressure. This allows the body to relax and stabilize, leading to a more accurate reading. Choice A is incorrect because using a cuff that is too loose can result in inaccurate readings. Choice B is incorrect as the cuff should be placed directly on the bare skin. Choice D is incorrect as using the same arm for each reading is important for consistency in monitoring, but sitting quietly before measuring is crucial for accuracy.

5. A client is taking sucralfate. Which of the following client statements indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Sucralfate is most effective when taken 1 hour before meals to protect the stomach lining. Option B is incorrect because sucralfate should not be taken after meals. Option C is incorrect because sucralfate is typically taken on a regular schedule, not just when symptoms occur. Option D is incorrect because sucralfate should not be taken with milk, as it can interfere with its effectiveness.

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