RN ATI LEADERSHIP ONLINE PRACTICE 2023 B
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES A+ GRADED
Which of the following findings should the
... [Show More] nurse identify require follow-up by the
provider? Select the 6 findings that require immediate follow-up.
Exhibit 1:
Day 1, 1715:
Client is 6 hr postoperative following abdominal surgery. Client is resting and easily
awakened. Alert and oriented to person, place, and time. Incision has moderate amount
of serous sanguineous draining on dressing. Abdominal dressing is intact. States pain
level is a 4 on a 0 to 10 pain scale. Bowel sounds are normoactive. Client tolerating sips
of water. Urinary output 320 mL in last 4hr.
Day 1, 2030:
Nurse enters room client's room. Client is restless and short of breath. Client rates pain
as an 8 on a scale of 0 to 10, saying,
"My abdomen hurts so bad." Nurse notes dressing site has large amounts of bright red
blood.
-Blood pressure
-Bowel sounds
-Pain level
-Respiratory rate
-Urinary output
-Heart rate
-Orientation status
-Oxygen saturation - Answer-When analyzing cues, the nurse should identify that an
increase in heart rate, respiratory rate, a pain level of 8 on a scale of 0 to 10, a large
amount of bright red blood on the client's abdominal dressing, along with a decrease in
blood pressure and oxygenation saturation are manifestations of hemorrhage.
Therefore, the nurse should notify the client's provider of these findings immediately.
A charge nurse is reviewing the plan of care for a client who has active herpes simplex
lesions. Which of the following interventions is appropriate for the plan of care?
a. Admit the client to a private room with negative-pressure airflow.
b. Wear a gown and gloves when caring for the client.
c. Have the client wear a mask during transport.
d. Wear a face mask and eye protection when caring for the client. - Answer-b. Wear a
gown and gloves when caring for the client.
The nurse should use contact precautions when caring for clients who have an infection
from herpes simplex. Barriers with gloves and gowns are mandatory. [Show Less]