LPN ATI fundamental exam
LPN ATI fundamental exam ( 53 Questions)
A nurse is caring for a client who is postoperative following abdominal surgery. Nurses Notes:
Neurological findings, incisional drainage, Urinary cutout, Client received from PACU with initial vital signs recorded. The client is drowsy but aroused by verbal stimuli. The client is oriented to person, place, and time. The client can move all extremities. Hypoactive bowel sounds. Abdominal dressing is intact with drainage noted. An indwelling urinary catheter is in place and draining yellow urine. Infusing lactated Ringer's solution at 100 mL/hr to the right forearm. The client is positioned for comfort and side rails are up x 2. The call light is within reach of the client.
Select the findings the nurse should report to the provider.
The neurological findings were already noted in the nurse's initial assessment, and the client's orientation and movement of extremities are within the expected range postoperatively.
Therefore, it does not require immediate reporting.
Incisional drainage is a significant finding, and any change or concern in the drainage should be reported to the provider to assess for signs of infection or other complications.
Monitoring urinary output is essential, especially in a postoperative client, as it helps assess renal function and hydration status. Any significant changes in urinary output should be reported to the provider promptly.
The client's reported pain level of 6 on a scale of 0 to 10 indicates moderate pain, and the provider should be informed to address the pain and consider adjustments to the pain management plan.
No explanation
No explanation
A: The neurological findings were already noted in the nurse's initial assessment, and the client's orientation and movement of extremities are within the expected range postoperatively.
Therefore, it does not require immediate reporting.
B: Incisional drainage is a significant finding, and any change or concern in the drainage should be reported to the provider to assess for signs of infection or other complications.
C: Monitoring urinary output is essential, especially in a postoperative client, as it helps assess renal function and hydration status. Any significant changes in urinary output should be reported to the provider promptly.
D: The client's reported pain level of 6 on a scale of 0 to 10 indicates moderate pain, and the provider should be informed to address the pain and consider adjustments to the pain management plan.