a nurse is assessing a client who is postoperative following a gastric bypass which of the following findings should the nurse report to the provider

ATI RN

ATI RN Exit Exam Quizlet

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

A. Heart rate of 78/min
B. Oxygen saturation of 95%
C. Urine output of 30 mL/hr
D. Serosanguineous wound drainage

Correct answer: C

Rationale: In a postoperative client, a urine output of 30 mL/hr is a concerning finding as it indicates oliguria, which may suggest dehydration or kidney impairment. Adequate urine output is essential for monitoring renal function and overall fluid status. A heart rate of 78/min is within the normal range for an adult. An oxygen saturation of 95% is acceptable and indicates adequate oxygenation. Serosanguineous wound drainage is expected in the early postoperative period and is not a cause for immediate concern unless it becomes excessive or changes character.

2. What is the first action to take when a patient experiences a seizure?

A. Protect the patient from injury
B. Administer oxygen
C. Administer IV fluids
D. Administer anti-seizure medication

Correct answer: A

Rationale: The first action to take when a patient experiences a seizure is to protect the patient from injury. This is crucial to prevent harm during the seizure. Administering oxygen, IV fluids, or anti-seizure medication may be necessary based on the patient's condition, but ensuring their safety by removing harmful objects, cushioning their head, and keeping the area clear is the immediate priority. Administering oxygen, IV fluids, or medication would come after ensuring the patient's safety.

3. When should healthcare professionals perform hand hygiene?

A. Before and after patient contact
B. Before and after performing procedures
C. After using the restroom
D. After touching contaminated surfaces

Correct answer: A

Rationale: Healthcare professionals should perform hand hygiene before and after patient contact to prevent the spread of infections. While choices B, C, and D are also important times to practice hand hygiene, they are not as crucial as before and after patient contact because patient contact poses a higher risk of transmitting infections.

4. What is the initial action a healthcare provider should take when a patient presents with chest pain?

A. Administer aspirin
B. Give oxygen therapy
C. Obtain ECG
D. Prepare for surgery

Correct answer: C

Rationale: The correct initial action when a patient presents with chest pain is to obtain an ECG. This helps assess the heart's electrical activity and determine the cause of chest pain. Administering aspirin or oxygen therapy may be necessary later based on the ECG findings, but obtaining an ECG is the priority to evaluate the cardiac status. Surgery preparation is not the initial action for chest pain and should only be considered after a thorough assessment.

5. A nurse is assessing a client who is receiving opioid analgesics for pain management. Which of the following findings should the nurse report to the provider?

A. Respiratory rate of 20/min
B. Blood pressure of 118/76 mm Hg
C. Heart rate of 88/min
D. Oxygen saturation of 94%

Correct answer: C

Rationale: The correct answer is C. A heart rate of 88/min is a normal finding; therefore, it does not require immediate reporting to the provider. The respiratory rate of 20/min, blood pressure of 118/76 mm Hg, and oxygen saturation of 94% are also within normal ranges and do not indicate any immediate concerns. However, a serum potassium level of 3.0 mEq/L indicates hypokalemia, which can be a serious issue and should be reported to the provider for further evaluation and management.