ATI RN
ATI Fundamental Exams Questions
Extract:
Nurses' Notes
Client is 4 hr postoperative following an open appendectomy. Client is alert and oriented to person, place, and time. Abdominal surgical site has small amount of serous sanguineous drainage on dressing. Dressing is intact. Client reports pain as a 5 on a scale of 0 to 10. Lung sounds are diminished in posterior lobes. Bowel sounds are hypoactive in all 4 quadrants. Last bowel movement was yesterday.
Vital Signs
Blood pressure 162/76 mm Hg
Heart rate 98/min
Respirations 24/min
Temperature 37.1° C (98.9° F)
Oxygen saturation 84% on room air
Question 1 of 5
A nurse is caring for a client who is postoperative following an open appendectomy.Exhibits Complete the following sentence by using the list of options.The client is at risk for developing -------------- as evidenced by the client’s ---------------------------
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
Rationale:
- Hypoxia (
A) is a common risk postoperatively due to anesthesia effects and potential respiratory complications.
- Respiratory assessment (
B) is crucial to monitor for hypoxia, ensuring early detection and intervention.
- Fever (
C) is a potential condition postoperatively, but not as directly linked to the client's postoperative state.
- Heart rate (
D) and Blood Pressure (E) are important parameters to monitor postoperatively, but not specifically indicative of hypoxia in this scenario.
Summary: Monitoring for hypoxia through respiratory assessment and monitoring heart rate and blood pressure are key actions to take for a postoperative client following an open appendectomy. Fever is a potential condition to watch for, but not directly related to the risk of hypoxia in this case.
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Question 2 of 5
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Question 5 of 5
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