a nurse is caring for a client who is 2 hr postoperative following an inguinal hernia repair which of the following findings should the nurse report t
Logo

Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

1. A nurse is caring for a client who is 2 hr postoperative following an inguinal hernia repair. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: A low urine output of 20 mL/hr, less than the expected 30 mL/hr or more, could indicate renal impairment or inadequate fluid status postoperatively. In this scenario, early detection and intervention are crucial to prevent further complications. The other findings - heart rate of 88/min, pain rating of 4, and blood pressure of 110/70 mm Hg - are within normal limits for a client 2 hr postoperative following an inguinal hernia repair and do not raise immediate concerns.

2. A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?

Correct answer: B

Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.

3. A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as an indication of digoxin toxicity?

Correct answer: D

Rationale: Corrected Rationale: Blurred vision is a classic sign of digoxin toxicity, indicating a potential overdose. It is crucial to recognize this symptom promptly and report it to the healthcare provider for immediate intervention. Bradycardia and nausea are common side effects of digoxin but not specific indicators of toxicity. Tachycardia is unlikely in digoxin toxicity since it usually causes a decrease in heart rate.

4. A nurse is providing discharge teaching to a client who is postoperative following a mastectomy. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction for the nurse to include is to advise the client to avoid using deodorant until the incision heals. Using deodorant can lead to skin irritation, which should be prevented following a mastectomy. Choice B is incorrect because performing arm exercises should typically be delayed until recommended by the healthcare provider to prevent strain on the surgical site. Choice C is incorrect as tight-fitting clothing can increase discomfort and hinder proper healing. Choice D is also incorrect because initiating arm exercises should be based on the healthcare provider's guidance and not a specific timeframe.

5. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Jugular vein distention. In left-sided heart failure, the left ventricle fails to efficiently pump blood to the body, causing increased pressure in the pulmonary circulation. This increased pressure can lead to symptoms like jugular vein distention, as blood backs up in the pulmonary circulation and causes congestion. Choices A, B, and D are incorrect: Peripheral edema is more commonly associated with right-sided heart failure, cough with frothy sputum is a sign of pulmonary edema which can occur in left-sided heart failure but is not as specific as jugular vein distention, and dependent edema is also more indicative of right-sided heart failure due to fluid retention and increased venous pressure in the systemic circulation.

Similar Questions

A client with chronic kidney disease is receiving dietary teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
A nurse is caring for a client who has a pulmonary embolism. Which of the following findings indicates the effectiveness of the treatment?
A nurse is caring for a client who has a chest tube. Which of the following findings should the nurse report to the provider?
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
A nurse is assessing a client who is experiencing auditory hallucinations. What question should the nurse ask?

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