NursingPlex
    Sign In
    Ati RN Fundamentals 2023 proctored exam

    A nurse is caring for a client on a medical surgical unit. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should first follow up on the client's dropdownanddropdown.

    Explanation & Rationale

    Rationale for Correct Choices: Oxygen saturation: The client's oxygen saturation has dropped to 90%, which is below the acceptable range of 92-100% for postoperative patients. This decrease in oxygen saturation needs immediate attention as it could indicate respiratory compromise or early signs of hypoxia. Behavioral findings: The client expresses a feeling of "something is wrong" and appears agitated, which may signal a complication, such as pain, anxiety, or more serious issues like internal bleeding or a developing embolism. The nurse should address the client's behavioral findings promptly to identify the cause. Rationale for Incorrect Choices: Pain: The client rates incisional pain as 5 out of 10, which is moderate but not critical. While pain management is important, it is not the primary concern in this case given the client’s symptoms of agitation and decreased oxygen saturation. WBC count: The WBC count is mildly elevated (10,800/mm³), which could indicate a mild inflammatory response, possibly due to surgery. However, it is not as urgent as addressing the drop in oxygen saturation and the client’s behavioral changes. Bowel findings: Hypoactive bowel sounds are expected following abdominal surgery and are not immediately concerning. The client’s bowel status does not require urgent follow-up compared to their oxygen saturation and behavioral symptoms.

    🔒 Submit your answer to reveal
    📋 View Case Study