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ATI Comprehensive Predictor 2023 Exit exam A
Total Questions : 138
Showing 10 questions, Sign in for morePostoperative day 2
0600:
- Urine output over 12 hr was 750 mL pink urine.
- Fluid intake over 12 hr was 800 mL
1800:
- Urine output over 12 hr was 500 mL pink urine.
- Fluid intake over 12 hr was 1500 mL.
A nurse is caring for a postoperative client following a perineal prostatectomy.
For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
Potential Order:.
Explanation
The correct answer is choice A. Applying warm compresses to the incision site is anticipated for the client, as it can help reduce swelling and pain.
The other choices are contraindicated for the following reasons:
- Choice B: Maintaining bed rest for 2 days postoperatively is contraindicated, as it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, and pneumonia. The client should be encouraged to ambulate as soon as possible after surgery.
- Choice C: Irrigating indwelling urinary catheter with 50 mL of normal saline is contraindicated, as it can introduce bacteria into the bladder and cause infection. The catheter should be kept patent and draining without irrigation unless there is a specific order from the provider.
- Choice D: Administering enema to relieve constipation is contraindicated, as it can increase the pressure in the pelvic area and cause bleeding or damage to the surgical site. The client should be given stool softeners and laxatives to prevent constipation.
- Choice E: Placing a blanket roll under the client’s knees while in bed is contraindicated, as it can impair blood circulation and cause thrombophlebitis. The client should avoid flexing the knees excessively and elevate the legs slightly when lying down.
0900:
Client reports, "I'm bloated and my stomach hurts."
History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal.
Past medical history: Osteoarthritis.
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco.
Current medications: Ibuprofen 800 mg three times daily PRN arthritis pain.
Physical Examination:
- General: client appears uncomfortable, diaphoretic.
- Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale.
- Respiratory: bilateral breath sounds clear.
- Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding
- Neurological: oriented x 3 (person, place, and time).
0900:
Hemoccult stool positive (negative).
H. pylori positive (negative).
WBC count 6,700/mm (5,000 to 10,000/mm). Hemoglobin 9.1 g/dL(14to 18g/dL).
Hematocrit 27% (40% to 52%).
0900:
- Blood pressure 90/50 mm Hg.
- Heart rate 118/min.
- Respiratory rate 18/min
- Temperature 37.5° C (99.5° F).
- ain rated as 7 on a scale of 0 to 10.
- Oxygen saturation 98% on room air.
The nurse reviews the entries in the medical record.
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
Explanation
Answer is… Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client’s medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer’s solution are not indicated nursing actions for the client.
Explanation:.
- Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client’s vital signs and symptoms closely.
- Documenting the blood product transfusion in the client’s medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion.
- Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after.
- Titrating the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client’s condition, weight, and response to the transfusion, not on a fixed target.
- Starting an IV bolus of lactated Ringer’s solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.
0400:
57-year-old male client presents to the emergency department with severe abdominal and epigastric pain that began about 12 hr ago. Client rates pain as a 7 on a 0 to 10 pain scale. Client reports pain worsens after eating and radiates into his back. States is nauseous and has had several episodes of vomiting, i Reports some shortness of air and increased pain when lying । flat.
Client is alert and oriented x4 but appears ill. Sclera and palate noted to be yellow. Abdomen distended, rigid, and tender to palpation. Skin turgor poor.
Client reports consuming 3 to 4 alcoholic drinks per day, denies use of other substances. No known allergies.
0730:
Will admit to medical-surgical unit for treatment of pancreatitis. Treatment plan discussed with client.
0330:
Temperature 38.4° C (101.1 ° F). Heart rate 120/min.
Respiratory rate 24/min.
Blood pressure 100/66 mm Hg. SpO2 94% on room air.
0800:
Temperature 38° C (100.4° F). Heart rate 106/min.
Respiratory rate 22/min.
Blood pressure 106/68 mm Hg.
SpO2 98% on O2 @ 2 L/min via nasal cannula.
Day 1,0330:
Client presents for evaluation of severe pain in upper abdomen that radiates into his back. States pain began approximately 12 hr ago and is worse when he is supine or after he eats. Rates pain as a 7 on a 0 to 10 pain scale. Sclera noted to be yellow. Heart rate regular, lungs clear to auscultation. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces during palpation. Reports last bowel movement was yesterday. Denies recent illnesses, takes no prescribed medications. Client is alert and oriented x 4.
Day 1,0800:
Report provided to medical-surgical nurse. Client transferred to medical-surgical unit via gurney.
Day 1,0430:
- Amylase 640 units/L (30 to 220 units/L).
- Lipase 220 units/L (0 to 160 units/L).
- Bilirubin (total) 3.7 mg/dL (0.3 to 1 mg/dL).
- Calcium 8.1 mg/dL (9 to 10.5 mg/dL).
- Glucose (casual) 215 mg/dL (< 200 mg/dL).
- Hemoglobin 20 g/dL (14 to 18g/dL).
- Hematocrit 60% (42% to 52%).
- WBC count 18,000/mm (5,000 to 10,000/mm).
- Platelet count 160,000/mm (150,000 to 400,000/mm).
A nurse in an emergency department is caring for a client. ​​​​​​
The nurse is preparing to notify the provider about the clients current condition.
For each potential provider prescription click to specify if the prescription is anticipated or contraindicated for the client.
Explanation
Answer is…
The following provider prescriptions are anticipated or contraindicated for the client:.
- Insert an indwelling urinary catheter. Anticipated. This prescription is anticipated because the client may have oliguria or anuria due to dehydration, hypovolemia, or renal impairment caused by pancreatitis. A urinary catheter can help monitor the urine output and fluid status of the client.
- Insert a nasogastric tube and maintain low intermittent suction. Anticipated. This prescription is anticipated because the client may have nausea, vomiting, and abdominal distension due to pancreatitis. A nasogastric tube can help decompress the stomach, reduce pancreatic stimulation, and prevent aspiration.
- Administer lactated Ringer’s 1 L via IV bolus. Anticipated. This prescription is anticipated because the client may have hypovolemia, hypotension, and electrolyte imbalances due to pancreatitis. Lactated Ringer’s solution can help restore fluid and electrolyte balance, improve tissue perfusion, and prevent shock.
- Administer famotidine 20 mg via intermittent IV infusion twice daily. Anticipated. This prescription is anticipated because the client may have gastric hypersecretion and peptic ulcer disease due to pancreatitis. Famotidine is a histamine-2 receptor antagonist that can help reduce gastric acid production, protect the gastric mucosa, and promote healing of ulcers.
A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?
A nurse is setting up a sterile field to perform wound irrigation for a client.
Which of the following actions should the nurse take when pouring the sterile solution?
A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?
A nurse is caring for a client. Laboratory Results
1300:
Cardiac troponin T less than 0.1 ng/mL (less than 0.1 ng/mL). LDL 110 mg/dL (less than 130 mg/dL).
Total cholesterol 230 mg/dL (less than 200 mg/dL).
Complete the following sentence by using the list of options: After notifying the provider, the nurse should first:
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?
A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications.
Which of the following information should the nurse include in the teaching?
A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?
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Brandi: our instructors have taught us to "palm the label" when performing sterile or any procedure using saline smh ~ 3w ago