the nurse is caring for the client recovering from intestinal surgery which assessment finding would require immediate intervention

ATI RN

ATI RN Custom Exams Set 4

1. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

A. Presence of thin pink drainage in the Jackson Pratt
B. Guarding when the nurse touches the abdomen
C. Tenderness around the surgical site during palpation
D. Complaints of chills and feeling feverish

Correct answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. This finding suggests a systemic response to infection, which can be life-threatening if not promptly addressed. Options A, B, and C are common postoperative findings and may not necessarily require immediate intervention unless accompanied by other concerning signs or symptoms.

2. The HCP orders cultures of the urethral urine, bladder urine, and prostatic fluid. Which instructions would the nurse teach to achieve the first two (2) specimens?

A. Collect the first 15 mL in one jar and then the next 50 mL in another
B. Collect three (3) early morning, clean voided urine specimens
C. Collect the specimens after the HCP massages the prostate
D. Collect a routine urine specimen for analysis

Correct answer: A

Rationale: The correct answer is to collect the first 15 mL in one jar and then the next 50 mL in another. This method allows for accurate cultures of urethral and bladder urine. Choice B is incorrect because it does not specify the correct method for collecting urethral and bladder urine separately. Choice C is incorrect because prostatic fluid is a separate specimen that does not require prostatic massage for collection. Choice D is incorrect as it suggests collecting a routine urine specimen, which does not fulfill the HCP's orders for specific cultures.

3. Who is at higher risk for drug-nutrient interactions?

A. Infants
B. People with diabetes
C. Women of childbearing age
D. Older men and women

Correct answer: D

Rationale: Older men and women are at higher risk for drug-nutrient interactions due to factors such as polypharmacy and physiological changes. Polypharmacy, common in older adults, increases the likelihood of interactions between drugs and nutrients. Physiological changes that occur with aging can affect how drugs and nutrients are absorbed, distributed, metabolized, and excreted in the body. Infants, people with diabetes, and women of childbearing age are not typically considered high-risk groups for drug-nutrient interactions compared to older adults.

4. Which laboratory data indicate the client’s pancreatitis is improving?

A. The amylase and lipase serum levels are decreased
B. The white blood cell count (WBC) is decreased
C. The conjugated and unconjugated bilirubin levels are decreased
D. The blood urea nitrogen (BUN) serum level is decreased

Correct answer: A

Rationale: The correct answer is A. Amylase and lipase are specific markers for pancreatitis. A decrease in their serum levels indicates improvement in pancreatitis. Choice B, a decreased white blood cell count (WBC), is more indicative of an improvement in infection rather than pancreatitis. Choices C and D, decreased bilirubin levels and blood urea nitrogen (BUN) levels respectively, are not specific markers for pancreatitis improvement.

5. Which of the following is the primary enlisted personnel performing nursing care duties at the various levels of health care?

A. 68A30
B. 68WM6
C. Physician assistant
D. 6.80E+21

Correct answer: B

Rationale: The correct answer is B: '68WM6'. The 68WM6 (Practical Nurse) is the primary enlisted personnel responsible for performing nursing care duties at various levels of health care. This choice is correct as it specifically identifies the enlisted personnel role related to nursing care. Choice A (68A30) is incorrect as it does not pertain to nursing care duties. Choice C (Physician assistant) is incorrect as physician assistants are not typically enlisted personnel. Choice D (6.80E+21) is incorrect as it is a numerical value and not a designation for enlisted personnel.