ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 14 Questions
Question 1 of 5
The nurse is completing an assessment of the client prior to surgery. What area(s) of the client assessment should the nurse question further? Select all that apply.
Correct Answer: A,B,C,D
Rationale: When preparing a client for surgery, these areas need to be addressed: skin preparation, elimination, attire/grooming, prosthesis, foods and fluids, and care of valuables. In addition, medication, activity, and the client's support system must be assessed. Dietary preferences of the client would not be a priority during the preoperative assessment.
Question 2 of 5
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?
Correct Answer: C
Rationale: Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.
Question 3 of 5
The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?
Correct Answer: B
Rationale: A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met.
Tolerating sips of water, breathing calmly, and reports of hunger are components of meeting the outcome of functioning.
Question 4 of 5
The nurse is caring for a postoperative client who reports difficulty urinating. The client does not have a urinary catheter in place. Which nursing action(s) are most appropriate at this time? Select all that apply.
Correct Answer: A,B,D,E
Rationale: The nurse encourages the client to void within 8 hours of surgery to minimize the risk of a urinary tract infection. Ambulating the client to the bathroom promotes normal body positioning for urination. Running water is a common psychological strategy to cause urination. Offering to catheterize is a last option, and a prescription for catheterization must be in place for the nurse to proceed.
Question 5 of 5
The nurse is caring for a client who is 2 hours postoperative. The client states, 'I am nauseated.' Which action(s) should the nurse perform? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Nausea is a frequent symptom in the postoperative period. When a client reports nausea, the nurse should provide an emesis basin in case the client vomits, check the medication administration record to provide a prescribed antiemetic, obtain vital signs per postoperative protocol, and encourage deep breathing. Liquids should be held until the nausea subsides.