a nurse is caring for a client who is postoperative following a cholecystectomy which of the following findings should the nurse report to the provide
Logo

Nursing Elites

ATI RN

ATI RN Exit Exam

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

Correct answer: D

Rationale: Bile-colored drainage from the surgical site can indicate a bile leak, which is an abnormal finding and should be reported. A blood pressure of 110/70 mm Hg and a temperature of 37.2°C (99°F) are within normal ranges for a postoperative client. Serosanguineous wound drainage, which is a mix of blood and serum, is expected following a surgery like cholecystectomy. Therefore, choices A, B, and C are not findings that require immediate reporting.

2. A nurse is caring for a client who is 1 day postoperative following a below-the-knee amputation. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action the nurse should take is to place the client in a prone position for 30 minutes four times a day. This position helps prevent contractures after an amputation by stretching the hip flexors and preventing shortening of the residual limb. Keeping the residual limb flat on the bed (Choice A) may lead to contractures. Elevating the residual limb on a pillow (Choice B) can also cause contractures and hinder proper healing. Keeping the residual limb dependent (Choice D) is not recommended as it does not promote proper positioning and circulation.

3. What is the initial nursing action for a patient presenting with chest pain?

Correct answer: A

Rationale: The correct initial nursing action for a patient presenting with chest pain is to administer aspirin. Aspirin helps reduce the risk of further clot formation in patients experiencing chest pain, as it has antiplatelet effects. Repositioning the patient, providing pain relief, or preparing for surgery are not the first-line interventions for chest pain. Repositioning the patient may be necessary to ensure comfort and safety, pain relief can be provided after further assessment and diagnostic tests, and preparing for surgery would only be considered after a thorough evaluation and confirmation of the need for surgical intervention.

4. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.

5. When collecting a sputum specimen from a client with tuberculosis, what action should the nurse take?

Correct answer: A

Rationale: The correct answer is to obtain the specimen immediately upon the client waking up. Collecting sputum early in the morning provides the best sample for tuberculosis testing. Option B is incorrect because waiting a day can decrease the accuracy of the specimen. Option C is incorrect as it does not specify the optimal timing for specimen collection. Option D is incorrect as sterile gloves should be worn for infection control but do not specifically relate to the timing of specimen collection.

Similar Questions

A nurse is planning care for a client who has pneumonia. Which of the following actions should the nurse take to promote airway clearance?
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following actions should the nurse take?
A healthcare provider is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?
A client who is at 12 weeks of gestation and has hyperemesis gravidarum is being cared for by a nurse. Which of the following laboratory values should the nurse report to the provider?
A client with osteoporosis should be encouraged to perform which of the following interventions as part of the plan of care?

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