When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?

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Adult Medical Surgical ATI Questions

Question 1 of 5

When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

Justin Mack, 20, was critically injured in a motorcycle accident and is not expected to survive. His parents, after arriving at the hospital from several hundred miles away, are asked to give important information about Justin, including:

Correct Answer: B

Rationale: Finding out about his childhood immunizations is of minor importance, given the prognosis. Getting information about whether Justin expressed the desire to donate his organs would be important at this time. Asking about the number of siblings might be a conversation opener, but is not of high importance to Justin's care. Previous hospitalizations and surgeries are irrelevant unless the organ donation is being considered, and this would then be important to learn.

Question 3 of 5

A 35-year-old female client has returned to her room following surgery on her right femur. She has an IV of D5 1/2 NS infusing at 125 cc/hr, and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. The client last voided 5 1/2 hours ago when she was given her preoperative medication. To monitor and promote the return of urinary function after surgery, the nurse should:

Correct Answer: C

Rationale: Provision of food and fluids promotes bowel elimination. Postoperative nutritional needs are physician determined, not client determined. Increasing IV fluids postoperatively will not cause a client to void. Any change in the rate of administration of IV fluids is determined by the physician, not the nurse. If the postoperative client with normal kidney function cannot void 8 hours after surgery, the client is retaining urine. The client may need catheterization or medication. The physician will provide orders for either, as necessary. While morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.

Question 4 of 5

A 44-year-old male client had abdominal surgery this morning. The nurse noticed a small amount of bloody drainage on the client's surgical dressing. This type of drainage is:

Correct Answer: C

Rationale: Drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Purulent drainage usually indicates infection. This drainage should not be seen initially from a surgical incision. An incision with a Penrose drain may be expected to have a moderate amount of serosanguineous drainage in the first 24 hours, but in general drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.

Question 5 of 5

Yesterday, a male client had a transurethral resection of the prostate (TURP). Today, the client is concerned about the small amount of blood found in his urine. The nurse should explain to the client that the blood:

Correct Answer: C

Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. The client will continue to have a small amount of hematuria even after the Foley catheter is removed. Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. Irrigating the bladder will not remove the hematuria. Irrigation is performed to remove blood clots and to facilitate urinary drainage.

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