a nurse is assessing a postoperative patient for signs of infection which finding is most concerning
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?

Correct answer: C

Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.

2. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection?

Correct answer: B

Rationale: The correct answer is B: Teaching the patient to select nutritious foods. A nutritious diet plays a crucial role in strengthening the body's immune system, making it more capable of fighting off infections. Vitamins, minerals, and other nutrients found in healthy foods support immune function and overall health. Teaching the patient about taking a temperature (choice A) may be important for monitoring for signs of infection but does not directly decrease the risk of infection. Teaching about the effects of alcohol (choice C) and fall prevention (choice D) are important aspects of patient education but are not directly related to decreasing the risk of infection in a susceptible patient.

3. A client is undergoing chemotherapy and expresses concern about hair loss. What is the best response?

Correct answer: D

Rationale: The best response when a client undergoing chemotherapy expresses concern about hair loss is to advise them that chemotherapy causes temporary hair loss. This response provides accurate information to the client about the side effect they are experiencing. Choice A is incorrect because it may provide false reassurance as for some individuals, hair loss can be a challenging experience. Choice B is not the best initial response as addressing the client's concerns and providing information should come first. Choice C is not the most appropriate response as cutting hair short may not necessarily prevent hair loss and does not address the client's concerns about the temporary nature of chemotherapy-induced hair loss.

4. Which of the following is a primary focus of tertiary prevention in mental health?

Correct answer: C

Rationale: The correct answer is C: Rehabilitation and prevention of further deterioration. Tertiary prevention in mental health aims to provide interventions and support to individuals who already have a mental illness to prevent further deterioration and promote recovery. Choice A, identifying early signs of mental illness, is more aligned with primary prevention which focuses on preventing the onset of mental health problems. Choice B, preventing the occurrence of mental health problems, pertains to secondary prevention which involves early detection and intervention to prevent the progression of mental health issues. Choice D, providing a safe environment to prevent harm, is important but it is not the primary focus of tertiary prevention which is more centered on rehabilitation and improving the quality of life for individuals with existing mental health conditions.

5. A nurse is completing an assessment of a recently widowed older adult client. He states he is unable to drive and is afraid to cook on the stove. Which of the following community resources should the nurse recommend?

Correct answer: B

Rationale: The correct answer is B: Meals on Wheels. Meals on Wheels is a community resource that provides food for older adults who are unable to cook for themselves, promoting independence and ensuring proper nutrition. Hospice care (choice A) focuses on providing comfort and support for individuals with life-limiting illnesses; it is not primarily aimed at providing meals. Home health services (choice C) typically involve skilled nursing care and therapy services provided in the home setting, rather than meal delivery. The American Association of Retired Persons (choice D) offers advocacy, support, and resources for older adults but does not directly address the specific needs mentioned in the client's situation.

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