a nurse is caring for a client who is 24 hr postoperative following an abdominal aortic aneurysm resection which of the following findings is a priori
Logo

Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A client is 24 hr postoperative following an abdominal aortic aneurysm resection. Which of the following findings is a priority to report?

Correct answer: D

Rationale: Urine output less than 30 mL/hr is indicative of decreased kidney function, potentially due to inadequate perfusion or other complications post-aneurysm resection. This finding requires immediate reporting to prevent further complications such as acute kidney injury. Serosanguineous drainage on the dressing, abdominal distention, and absent bowel sounds are also important postoperative assessments but are not as critical as impaired kidney function in this scenario.

2. A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.

3. A client with hypertension is being taught about dietary modifications by a nurse. Which of the following food choices by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Choosing fresh fruits and vegetables is a healthy choice for someone with hypertension as they are low in sodium and high in nutrients. Processed meats (A) are high in sodium and unhealthy fats, which can worsen hypertension. Canned vegetables (B) often have added sodium, so fresh is a better choice. Canned soups (D) are typically high in sodium and should be limited in a hypertensive diet.

4. A client with a new diagnosis of Graves' disease and a prescription for propylthiouracil (PTU) is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because propylthiouracil (PTU) can increase the risk of infection. Therefore, the client should be aware that this medication may compromise their immune system, making them more susceptible to infections. Reporting any signs of infection promptly to the provider is crucial for timely intervention and management. Choices A, B, and D are incorrect because reporting a sore throat, assuming lifelong medication intake, or experiencing decreased appetite are not directly related to the medication's side effects or risks.

5. A nurse is caring for a client who has a pressure ulcer. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D, 'Undermining.' Undermining occurs when the tissue under the wound edges erodes, indicating poor healing progress. This finding should be reported to the provider as it suggests delayed wound healing and may require intervention. Choice A, 'Eschar,' is a thick, hard, black/brown necrotic tissue that forms over a wound. While it indicates a non-healing wound, it is not as concerning as undermining. Choice B, 'Slough,' is a soft, moist, yellow/white tissue that is also a sign of necrosis. While the presence of slough indicates the need for wound cleaning and debridement, it is not as critical to report as undermining. Choice C, 'Granulation tissue,' is new tissue that forms during wound healing and is a positive sign. The presence of granulation tissue indicates that the wound is progressing through the healing stages and is not a finding that requires immediate reporting to the provider.

Similar Questions

What is the priority intervention for a patient with a severe allergic reaction?
A nurse is assessing a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?
What is the most important nursing action for a patient post-surgery?
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?
What is the most appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?

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