a nurse is caring for a client who is 2 hours postoperative following a thoracotomy which of the following findings should the nurse report to the pro
Logo

Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

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

Correct answer: C

Rationale: The correct answer is C. Chest tube drainage of more than 100 mL/hr may indicate active bleeding, which is a serious complication post-thoracotomy surgery. This finding should be reported to the healthcare provider immediately for further evaluation and intervention. Choices A, B, and D are within normal limits for a client 2 hours post-thoracotomy and do not require immediate reporting. Oxygen saturation of 95% is acceptable, and a heart rate of 88/min is within the normal range for an adult.

2. A nurse is reviewing the laboratory values of a client who is taking spironolactone. Which of the following values should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B: 'Potassium 5.2 mEq/L.' When a client is taking spironolactone, which is a potassium-sparing diuretic, monitoring potassium levels is crucial. A potassium level of 5.2 mEq/L is higher than normal and can lead to cardiac dysrhythmias, so it should be reported. Choices A, C, and D are within normal ranges and would not be of immediate concern when assessing a client taking spironolactone.

3. A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for insulin glargine. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction that the nurse should include is to inject insulin glargine once a day, at the same time each day. Insulin glargine is a long-acting insulin that provides a consistent level of insulin over 24 hours, helping to maintain stable blood glucose levels. Option B is incorrect because insulin glargine does not cause an immediate increase in blood glucose levels. Option C is important for preventing lipodystrophy but is not specific to insulin glargine administration. Option D is incorrect because insulin glargine is typically administered at the same time each day, regardless of meals.

4. What is the priority intervention for a patient with fluid overload?

Correct answer: A

Rationale: The correct answer is to administer diuretics. Diuretics help reduce excess fluid in cases of fluid overload, making it the priority intervention. Administering additional IV fluids (choice B) would exacerbate the problem by adding more fluid. Providing oral fluids (choice C) is not the priority as the excess fluid needs to be removed first. Chest physiotherapy (choice D) is not the primary intervention for fluid overload.

5. A nurse is caring for a client who has a new diagnosis of deep-vein thrombosis (DVT). Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct answer is to monitor the client's oxygen saturation level. Deep-vein thrombosis (DVT) increases the risk of pulmonary embolism, a life-threatening complication. Monitoring oxygen saturation helps in early detection of any signs of compromised respiratory function. Massaging the affected leg can dislodge a blood clot, leading to severe consequences. Applying heat through a heating pad can promote vasodilation and increase the risk of clot dislodgment. While mobility is essential in preventing DVT complications, encouraging excessive walking without proper assessment can potentially dislodge a clot and worsen the condition.

Similar Questions

A nurse is preparing to administer an IV medication to a client who has an allergy to latex. Which of the following actions should the nurse take?
A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?
A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?
A nurse is providing teaching to a client with asthma. Which of the following client statements indicates a need for further teaching?
A client with osteoporosis needs to increase calcium intake. Which of the following foods should be recommended by the nurse?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses