ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative following abdominal surgery. The client reports feeling like 'something opened up.' The nurse peels back the dressing to find separation of the incision with protrusion of intestinal tissue. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Cover the wound with a saline-soaked dressing. This action is appropriate because it helps to prevent further damage to the exposed intestinal tissue and maintains a moist environment to promote healing. Placing the client in Trendelenburg position (
A) is not recommended as it can increase intra-abdominal pressure and worsen the situation. Reinserting the protruding intestinal tissue (
B) should not be done by the nurse as it can lead to complications and is beyond the scope of nursing practice. Monitoring vital signs every 30 minutes (
D) is important but not the immediate priority in this situation where wound coverage is crucial.
Question 2 of 5
Correct Answer:
Rationale:
Question 3 of 5
Correct Answer:
Rationale:
Question 4 of 5
Correct Answer:
Rationale:
Question 5 of 5
Correct Answer:
Rationale: