a nurse is assessing a client who is 4 hours postoperative following abdominal surgery the clients blood pressure has dropped from 12080 mm hg to 9060
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?

Correct answer: B

Rationale: Checking the surgical site for bleeding is crucial in this situation as it helps determine if the drop in blood pressure is due to hemorrhage, a potential postoperative complication. Identifying and addressing bleeding promptly is essential to prevent further complications and stabilize the client's condition.

2. A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?

Correct answer: D

Rationale: Placing the client in a high Fowler's position is the best action in this situation as it helps to maximize lung expansion, improve breathing, and decrease the work of breathing. This position allows for better chest expansion, improving oxygenation and ventilation for the client in respiratory distress.

3. A healthcare provider is assessing a client immediately after the removal of the endotracheal tube. Which of the following findings should the provider report to the healthcare provider?

Correct answer: A

Rationale: Stridor is a high-pitched, harsh respiratory sound that can indicate airway obstruction. It is a serious finding that requires immediate attention as it may lead to respiratory compromise. Copious oral secretions, hoarseness, and sore throat are common but expected findings after endotracheal tube removal and do not typically require urgent intervention.

4. A client with chronic obstructive pulmonary disease (COPD) is being taught by a healthcare provider. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. While exercise is important for clients with COPD, daily exercise may be too strenuous. Clients should be encouraged to exercise regularly but should be advised to avoid overexertion. Statements A, B, and D demonstrate appropriate understanding and management of COPD symptoms.

5. A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

Correct answer: B

Rationale: When a client with COPD on oxygen therapy reports difficulty breathing, the priority action for the nurse is to assess the client's respiratory status. This involves evaluating the client's oxygen saturation levels, respiratory rate, effort of breathing, lung sounds, and overall respiratory distress. By assessing the client's respiratory status, the nurse can determine the severity of the situation and make appropriate decisions regarding further interventions, such as adjusting oxygen flow rate, providing respiratory treatments, or seeking emergency assistance if necessary.

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