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2024 ATI MEDICAL SURGICAL EXAM WITH 180 QUESTIONS
& CORRECT ANSWERS GRADED A WITH RATIONALES
- A nurse is reviewing the cause of gout with a group of nurses. Which of the following statements should the nurse make? A. "Uric acid levels drop and calcium forms precipitate." Rationale: With gout, clients have hyperuricemia, rather than a reduction in uric acid. B. "Tophi form in the kidneys and they impair the excretion of uric acid." Rationale: Tophi, or deposits in tissues near a joint, develop in chronic, late-stage gout. They are not part of the primary disease process. C. "The intra-articular deposition of urate crystals causes inflammation." Rationale: Gout, or gouty arthritis, develops when urate crystals deposit in joints and tissues and cause inflammation and pain. D. "Articular cartilage thins, leading to splitting and fragmentation." Rationale: Gout does not thin and fragment cartilage.
- A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendations should the nurse include in the teaching? A. Use Echinacea to manage joint pain. Rationale: The nurse may include the use of complementary and alternative therapies in the teaching. However, Echinacea is used for the treatment of the common cold, not osteoarthritis. Alternative therapies that are used for osteoarthritis include glucosamine, chondroitin, and topical capsaicin. B. Apply ice to the joint before exercising. Rationale: The nurse should recommend that the clients begin exercising immediately following the application of heat. This reduces pain and improves mobility, allowing for increased range-of-motion during exercises. Cold application may be applied following exercise to decrease discomfort and inflammation. C. Maintain a recommended body weight. Rationale: Obesity is a risk factor for the development of osteoarthritis. Maintenance of an ideal weight is one way a client can prevent added wear and tear on joints and promote overall joint health. D. Reduce the amount of purine in the diet. Rationale: The nurse should recognize that limiting purine in the diet, which is often found in organ meats, is recommended for clients who have gout.
- A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the
damage is done. Which of the following is the correct nursing response? A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." Rationale: With this response, the nurse uses the therapeutic communication technique of presenting reality by indicating her perception of the situation for the client. B. "It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it." Rationale: With this response, the nurse illustrates the nontherapeutic communication technique of giving reassurance, thus discouraging the client from further communication. C. "Exercise is good for you and good for your heart." Rationale: With this response, the nurse illustrates the nontherapeutic communication techniques of disagreeing and giving advice. D. "Your doctor is the expert here, and I’m sure he would only recommend what is best for you." Rationale: With this response, the nurse illustrates the nontherapeutic communication technique of defending.
- A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client’s low potassium level? A. Furosemide Rationale: Furosemide is a loop (high-ceiling) diuretic that inhibits the reabsorption of sodium and chloride and results in diuresis, which decreases potassium through excretion in the distal nephrons. Hypokalemia is an adverse effect of furosemide. B. Nitroglycerin Rationale: A potassium level of 2.4 mEq/L is not an adverse effect of nitroglycerin. Nitroglycerin is a vasodilator medication to treat angina. C. Metoprolol Rationale: A potassium level of 2.4 mEq/L is not an adverse effect of metoprolol. Metoprolol is a beta-blocker that slows the heart rate and improves contractility of the heart muscle. D. Spironolactone Rationale: Spironolactone is a potassium-sparing diuretic medication; therefore, hyperkalemia is an adverse effect of this medication.
- A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)
- A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB? A. Chest x-ray Rationale: A chest x-ray may be helpful for detecting old or new lesions that are large enough to be visualized. However, the client who has an HIV infection may have a normal x-ray or show infiltrates which would be expected in the client who has pneumonia. B. Sputum culture for acid-fast bacillus Rationale: Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis. C. Sputum smear Rationale: A sputum smear is able to detect the presence of mycobacterium, but it does not distinguish between mycobacterium tuberculosis and other strains of mycobacterium. D. Mantoux test Rationale: The Mantoux skin test is an effective screening tool, but it is unable to distinguish between an active case of TB and a client who has been, at some time in the past, exposed to TB. The results are also variable, depending upon the skill of the nurse administrating and reading the test.
- A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following client statements indicates an understanding of the teaching? A. "I can use either heat or ice to help relieve the discomfort." Rationale: The nurse should reinforce that different treatment modalities, such as heat or cold therapy, can be tried to determine which one is more effective for the client. Heat application can help with muscle relaxation in the area around the affected joint. The application of cold numbs nerve endings and decreases joint inflammation. B. "Ibuprofen is the first step in medication therapy for osteoarthritis." Rationale: The nurse should instruct the client that the primary medication of choice for the treatment of osteoarthritis is acetaminophen. NSAIDS, such as celecoxib and ibuprofen, might be tried if acetaminophen does not control discomfort. C. "I should limit physical activity to prevent further injury." Rationale: The nurse should encourage the client to include aerobic exercise and lower extremity strength training into her daily regimen. These activities have been shown to slow the progression of osteoarthritis and relieve the manifestations of the disorder. D. "I will elevate my legs by placing two pillows under my knees when I go to bed." Rationale:
The nurse should instruct the client to avoid the use of pillows under the knees as this contributes to the development of flexion contractures.
- A nurse is preparing to perform a 12-lead electrocardiogram. Which of the following instructions should the nurse provide to the client? A. "I will be placing electrodes on your breasts." Rationale: Correct placement of the electrodes involves placing six leads on the limbs and six leads on the chest in order to obtain an accurate electrocardiogram. The electrical current being monitored in the electrocardiogram would be altered through breast tissue. The nurse may request the client reposition the breasts, or the nurse may assist with positioning to allow correct electrode placement on the chest wall. B. "Try to hold your breath until this procedure is complete." Rationale: Although the client should lie as still as possible to prevent artifact, breathing normally is important during the electrocardiogram. Maintaining a regular respiratory pattern allows for oxygen saturation to occur, which is important for clients who might have a compromised cardiac status. C. "Try to remain still once I have attached the gel pads." Rationale: It is very important for the client to understand the importance of lying still during the electrocardiogram. Lying still will prevent artifact from occurring and allow for clear results when interpreted by the provider. D. "I will lower the head of your bed so you can lie flat." Rationale: The best position for the client is Semi-Fowler’s, which allows for better comfort and lung expansion as opposed to the supine position. Promoting lung expansion allows for better oxygenation for the client who may have a compromised cardiac status.
- A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications? A. Pneumonia Rationale: Pneumonia can develop with immobility, but generally takes longer than 24 hr. B. Fat embolism Rationale: The nurse should suspect that client has fat embolism syndrome. This complication develops within 12 to 48 hr of a fracture and can cause dyspnea, respiratory distress, alterations in mental status, tachycardia, and other manifestations. Older adults who have hip fractures are at greater risk. C. Pneumothorax Rationale: Although pneumothorax can cause some of the same manifestations, the client is not at risk
the following information should the nurse include? A. Apply heat to the injury during the first 12 hr. Rationale: The nurse should apply ice to the injury for the first 24 to 48 hr to reduce swelling. B. Maintain the affected extremity in a dependent position. Rationale: The nurse should elevate the affected extremity to reduce swelling. C. Perform passive range of motion (ROM) to an injured joint. Rationale: The nurse should immobilize the joint proximal and distal to the injury to promote healing and prevent further injury to the area. D. Compress the injury for 24 hr. Rationale: The nurse should apply compression for the first 24 to 48 hr to reduce swelling. 14.AA nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include? A. "Bloodshot eyes on the day of surgery should be reported to the provider." Rationale: Bloodshot eyes are an expected finding on the day of surgery. B. "Warm compresses should be applied to the eye three times daily." Rationale: Cold compresses should be applied to the eye. C. "Photophobia is expected for 2 to 3 days." Rationale: Photophobia is not an expected finding and should be immediately reported to the provider. D. "Vision will be greatly improved on the day of surgery." Rationale: Vision should be greatly improved on the day of surgery. This information should be included in the teaching. 15.AA nurse is reviewing the laboratory values of a client who is at risk for disseminated intravascular coagulopathy. Which of the following values should the nurse report to the provider? A. Platelets 156,000/mm Rationale: This platelet count is within the expected reference range and does not need to be reported to the provider. B. PT 12 seconds Rationale: This PT level is within the expected reference range and does not need to be reported to the provider.
C. PTT 64 seconds Rationale: This PTT level is within the expected reference range and does not need to be reported to the provider. D. Fibrinogen 85 mg/dL Rationale: This fibrinogen level is below the expected reference range and should be reported to the provider. A decreased fibrinogen level can result from its depletion during the blood clotting process. 16.AA nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? A. Ventricular depolarization Rationale: The QRS complex reflects ventricular depolarization. B. Slow repolarization of ventricular Purkinje fibers Rationale: A U wave appears when there is slow repolarization of ventricular Purkinje fibers. C. Atrial depolarization Rationale: The P wave reflects atrial depolarization, typically initiated in the sinoatrial node. D. Early ventricular repolarization Rationale: The ST segment reflects early ventricular repolarization.
- A nurse observes mild hand tremors in a client who has diabetes mellitus. Which of the following actions should the nurse take after obtaining a glucose meter reading of 60 mg/dL? A. Administer 15 g of carbohydrates. Rationale: The first step in preventing the client's blood glucose level from dropping further is to administer 15 to 20 g of carbohydrates. A client who is awake and can swallow can consume carbohydrates, such as glucose tablets or glucose gel, 120 mL (4 oz) of orange juice, 240 mL (8 oz) of skim milk, 6 saltine crackers, 3 graham crackers, or 6 to 10 hard candies. B. Retest the blood glucose level. Rationale: Retesting blood glucose delays treatment. The client is symptomatic and has a blood glucose level below the expected reference range. Administering 10 to 15 g of carbohydrates will increase the blood glucose and decrease the shakiness associated with hypoglycemia. C. Administer 1 mg of glucagon IM. Rationale: The nurse should administer glucagon to a client whose blood glucose level is so low that he is unable to swallow or swallowing poses a risk for aspiration. In a situation in which glucagon is administered, the nurse should follow the initial dose with another 1 mg if the client remains
The nurse should instruct the client that 1 cup of milk contains 15 g of carbohydrates. D. 1 cup regular ice cream Rationale: The nurse should instruct the client that ½ cup of regular ice cream contains 15 g of carbohydrates
- A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? A. Airway protection Rationale: When assessing and treating a client who has trauma, a systematic approach is taken during the primary survey. It begins with the assessment and interventions necessary to ensure a patent airway. B. Decreasing intracranial pressure Rationale: After managing the airway, breathing, and circulation, the nurse would assess and manage any disabilities. This involves a baseline assessment of the client’s neurologic status. C. Stabilizing cardiac arrhythmias Rationale: When using the airway, breathing, circulation approach to client care, the nurse would stabilize cardiac rhythms. However, it is not the priority focus of care. D. Preventing musculoskeletal disability Rationale: Preventing musculoskeletal disability is is completed during the secondary survey of the client who has trauma, following a head-to-toe assessment. It is not the priority focus of the nurse when using the airway, breathing, circulation approach to client care.
- A nurse is teaching a client who is taking metformin XR for type II diabetes mellitus. Which of the following instructions should the nurse include in the teaching? A. “Take the medication with a meal.” Rationale: The client should take metformin with a meal to avoid hypoglycemia and GI upset, and to provide the most absorption of the medication. B. “You may crush or chew the medication.” Rationale: The client should not crush or chew extended-release medication, because it can cause a rapid release of the medication leading to hypoglycemic response. C. “This medication may cause an increase in perspiration.” Rationale: Metformin does not cause an increase in perspiration. Sweating can indicate a hypoglycemic reaction.
D. “This medication may turn your urine orange.” Rationale: Metformin does not alter the color of urine. 22.AA rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? A. Inform the client that privileges are related to participation in therapy. Rationale: This response does not address the holistic needs of the client and could be interpreted as a threat. B. Limit visiting hours until the client begins to participate in therapy. Rationale: Limiting visiting hours could increase the client's withdrawn affect. C. Allow the client to control the timing and frequency of the therapy. Rationale: This action could be harmful if the client chooses to minimize or eliminate aspects of therapy. D. Establish a plan of care with the client that sets attainable goals. Rationale: The nurse should develop a plan of care for this client with mutually set goals. This action invests the client in the rehabilitation process, which encourages feelings of ownership for it, and sees the goals as more attainable. 23.AA nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. pulse and blood pressure findings Rationale: The nurse should assess the client's pain level routinely along with vital signs. A pain assessment should also be completed if the client has a change in condition, such as a new onset of chest pain, or following a procedure which can be uncomfortable for the client, such as x-rays which require the client to lay on a hard surface for extended periods of time. A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although vital signs can be used as a physiologic indicator, monitoring them is an objective method of evaluating pain and may not be a reliable means of assessing pain levels. Evidence-based practice indicates the nurse should use a different parameter first. B. behavioral indicators and effect Rationale: A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although behavioral indicators can be used, the nurse should recognize that pain behaviors are unique to each patient. Evidence-based practice indicates the nurse should use a different parameter first. C. scheduled treatments and client illness Rationale:
void because of pressure on the internal sphincter from the catheter balloon. C. Monitor the client's urine output every 6 hr. Rationale: The nurse should monitor the client's urinary output every 2 hr during the immediate postoperative period to ensure that the catheter is draining properly and to check the color of the urine and monitor the passing of clots. D. Weigh the client every evening. Rationale: The client who is receiving continuous bladder irrigation is at risk for fluid volume excess. The nurse should weigh the client every morning before breakfast to monitor the client for the risk transurethral syndrome. 26.AA nurse at a provider’s office receives a phone call from a client who reports nausea and unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse? A. Tell the client to take an antacid. Rationale: An antacid will offer no relief for a client who is experiencing nausea or epigastric discomfort, which is an indication of unstable angina or an acute myocardial infarction. B. Instruct the client to call 911. Rationale: The nurse should instruct the client to call 911 for transportation to the emergency department because the client is having unstable angina or an acute myocardial infraction. C. Tell the client to take another nitroglycerin tablet in 15 min. Rationale: The client who has no relief from taking nitroglycerin should not wait to take another tablet in 15 min, but should take a nitroglycerin within 5 min of taking the first dose. Nitroglycerin is taken to help dilate the coronary arteries for a client who has unstable angina. D. Advise the client to come to office. Rationale: Going to the provider’s office would unnecessarily delay treatment for a client experiencing unstable angina or an acute myocardial. 27.AA nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations? A. Increased urine output Rationale: Pacemaker malfunction is more likely to cause edema from retained fluid due to decreased cardiac output. B. Rapid pulse Rationale: A pacemaker is placed in order to initiate contractions at a set rate for clients who have bradycardia. A slow cardiac rhythm, bradycardia, may indicate malfunction of the pacemaker.
C. Fatigue Rationale: Pacemaker malfunction causes bradycardia and a drop in cardiac output. This can cause hypoxia, with classic manifestations of weakness, fatigue, and dizziness. D. Sneezing Rationale: Some types of pacemaker malfunction can cause prolonged hiccuping, not sneezing, due to phrenic nerve and diaphragmatic stimulation. 28.AA nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as increasing a client's risk for carpal tunnel syndrome? A. Truck driver Rationale: Although long-distance truck driving can place stress on many areas of the body, this is not the type of stress that typically causes carpal tunnel syndrome. B. Nursing assistant Rationale: Nursing assistants are more likely to develop back injuries than carpal tunnel syndrome. C. Elementary school teacher Rationale: Preschool or day care workers are more likely than elementary school teachers to develop carpal tunnel syndrome due to repeated lifting of children. D. Assembly line worker Rationale: Occupations that require continuous wrist movement, such as working on a factory assembly line, increase the risk for developing carpal tunnel syndrome.
- A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching? A. Exercise at least three times per week. Rationale: The nurse encourage the client to stay as active as possible and to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The client should try to walk at least three times per week and should slowly increase the amount of time walked over several months. Regular exercise strengthens the heart and cardiovascular system, thereby improving circulation and lowering blood pressure. B. Take diuretics early in the morning and before bedtime. Rationale: A client who is taking diuretics should take them in the early morning and early afternoon. The nurse instruct the client not to take the diuretics near bedtime to avoid sleep pattern disturbance secondary to increased urination. C. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. Rationale:
The nurse should expect a client who has compartment syndrome to display increased edema and report severe, unrelenting pain at the fracture site. D. Venous thromboembolism Rationale: The nurse should expect a client who has a venous thromboembolism to display a sudden onset of unilateral swelling of the leg and report pain or tenderness in the calf or groin areas. 32.AA nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care? A. Monitor the client's intake and output every 6 hr. Rationale: The nurse should monitor the client's intake and urinary output at least every 2 hr to assess the client’s response to fluid therapy. The client may require continual fluid therapy to correct the fluid imbalance. B. Offer the client 240 mL (8 oz) of oral fluids every 4 hr. Rationale: The nurse should offer 60 to 120 mL (2 to 4 oz) of fluids every 1 to 2 hr to manage the dehydration as well as prevent further dehydration. C. Check the client's IV infusion every 8 hr. Rationale: The nurse should assess the client's IV infusion site and the infusion to monitor for infiltration, extravasation, or phlebitis every hour. D. Administer furosemide to the client. Rationale: Furosemide is a loop diuretic that will further contribute to the client's dehydration. The nurse can administer medication to control possible causes of the dehydration, such as antibiotics for bacterial diarrhea, antiemetics for vomiting, and antipyretics for fever.
- A nurse on the day shift is preparing to change a client’s total parenteral nutrition (TPN) solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take? A. Hang dextrose 10% in water (D10W) until the TPN solution is delivered. Rationale: The nurse should hang D10W if the TPN runs out or is not available to hang. D10W is a hypertonic solution that will maintain glucose level and prevent rebound hypoglycemia. B. Saline lock the IV catheter after discontinuing the TPN solution. Rationale: Discontinuing the TPN can cause the client to have rebound hypoglycemic reaction because of the high glucose content of the TPN solution. C. Hang the IV fat emulsion solution. Rationale: The nurse should not hang the fat emulsion solution, because the solution is scheduled to infuse during the night, may cause rebound hypoglycemia, and cause the client to receive an
overdose of fat emulsion. D. Call the provider for new TPN orders. Rationale: The client has a current prescription for specific substances required in the TPN solution. The client’s weight, intake and output, and blood glucose are continuously monitored to determine therapeutic response to the TPN therapy. Asking the provider for a new order of TPN solution will delay therapy and could jeopardize the patency of the central line access.
- A nurse is planning care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan of care? A. Provide a high carbohydrate diet. Rationale: A client with hepatitis should have a diet high in carbohydrates due to altered nutrient metabolism. B. Administer acetaminophen for pain. Rationale: A client with hepatitis should avoid acetaminophen which is metabolized in the liver. C. Encourage eating three large meals daily. Rationale: A client with hepatitis should eat small frequent meals daily to provide adequate calories and nutrition. D. Include high protein snacks. Rationale: A client with hepatitis should consume protein in moderation to promote healing. 35.AA nurse is caring for a client who received a diagnosis of systemic scleroderma 5 years ago. The nurse plans to assess the client to document the disease's progression. In addition to skin changes, which of the following findings should the nurse expect? A. Periorbital edema Rationale: Manifestations of systemic scleroderma include edema of the hands, fingers, and sometimes the lower extremities. B. Excessive salivation Rationale: A client who has systemic scleroderma will experience decreased salivation, which increases the risk of dental caries and gum disease. C. Finger contractures Rationale: Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. Manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dryness of the mucous membranes. Contractures occur with advanced systemic scleroderma unless the client follows a regimen of range-of-motion and muscle-strengthening exercises, pain management, and joint protection.
following actions should the nurse take? A. Explain to the client that all patients feel that way prior to surgery. Rationale: The nurse provides false reassurance by not acknowledging the client’s negative emotions, which closes the opportunity for therapeutic communication. B. Suggest the client talk to the provider. Rationale: The nurse refusing to discuss the client’s negative emotions causes the client to feel rejected, which closes the opportunity for therapeutic communication. C. Ask the client what to expect tomorrow. Rationale: The nurse changes the subject by not acknowledging the client’s negative emotions, which closes the opportunity for therapeutic communication. D. Encourage the client to express negative emotions. Rationale: The nurse is acknowledging the client’s negative emotions, therefore providing open therapeutic communication. 39.AA nurse is providing care for a client who had a laparoscopic cholecystectomy. Which of the following is an appropriate nursing action? A. Place the client in a supine position postoperatively. Rationale: The nurse should place the client in Semi-Fowler's position to promote lung expansion. If needed, the nurse can use the lateral or Sims' position for a client who is unconscious to prevent aspiration. B. Encourage ambulation once fully awake. Rationale: The nurse should encourage ambulation once the client is fully awake to promote absorption of the carbon dioxide used during the laparoscopy. This minimizes the client's discomfort. The nurse should check the client for nausea before ambulating, and administer an anti-emetic medication if necessary. C. Offer the client ice cream postoperatively. Rationale: The nurse should offer foods low in fat to prevent nausea and vomiting. The nurse should also offer foods that are high in carbohydrates and protein to provide adequate nutrition. D. Instruct the client not to lift over 4.5 kg (10 lb). Rationale: The nurse should instruct the client not to lift more than 2.3 kg (5 lb) following surgery. 40.AA nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24 hr output totals indicates oliguria? A. 720 mL Rationale:
This urinary output is above the expected minimum output of 400 mL in 24 hr. B. 550 mL Rationale: This urinary output is above the expected minimum output of 400 mL in 24 hr. C. 380 mL Rationale: This urinary output indicates oliguria, which is defined as less than 400 mL of total output in 24 hr or less than 30 mL per hr. D. 600 mL Rationale: This urinary output is above the expected minimum output of 400 mL in 24 hr. 41.AA nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect? A. Ulcerative colitis Rationale: The nurse should identify ulcerative colitis as a chronic inflammatory condition that primarily affects the rectum. B. Cholecystitis Rationale: The nurse should identify cholecystitis as an inflammation of the gallbladder. C. Paralytic ileus Rationale: A paralytic ileus in a postoperative client is indicated by the absence of bowel sounds, abdominal distention, and the client passing no stool or flatus. It is often caused by bowel handling during surgery and opioid analgesic use. D. Wound dehiscence Rationale: The nurse should identify wound dehiscence as when the edges of the client's wound are no longer intact. 42.AA nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse’s priority? A. The client's ECG tracing shows irregular heart rate without P waves. Rationale: A client who has atrial fibrillation will have an irregularly irregular heart rate, absent P waves, and a variable ventricular rate; therefore, this is not the nurse’s priority finding. B. The client has an aPTT of 80 seconds. Rationale: A client who has atrial fibrillation may receive heparin to extend the clotting time and prevent the formation of clots. APTT result of 80 seconds is double the control value and indicates
