ATI Fundamentals NGN
Complete Review: Case
Studies, Rationales & Clinical
Judgment
Postoperative Client
A 68-year-old client is 8 hr postoperative following an abdominal
surgery. The client has an IV infusion, urinary catheter, oxygen at 2
L/min by nasal cannula, and a PCA pump. Vital signs: T 38.1°C
(100.6°F), HR 104/min, RR 24/min, BP 108/64 mm Hg, SpO₂ 92%.
1. Which finding requires the nurse's immediate attention?
A. Temperature of 38.1°C
B. Heart rate of 104/min
C. Respiratory rate of 24/min
D. SpO₂ of 92%
Answer: D. SpO₂ of 92%
Rationale: Oxygenation is the priority because impaired oxygenation
can rapidly become life-threatening. The nurse should assess airway
and breathing and intervene promptly.
2. Which assessment should the nurse perform first?
A. Inspect the surgical incision
B. Assess respiratory effort and breath sounds
C. Check urine output
D. Assess bowel sounds
,Answer: B. Assess respiratory effort and breath sounds
Rationale: The ABC framework prioritizes airway and breathing
before circulation or postoperative gastrointestinal assessment.
3. Which intervention is appropriate for preventing postoperative
atelectasis?
A. Restrict oral fluids
B. Encourage incentive spirometry
C. Maintain strict bed rest
D. Limit coughing
Answer: B. Encourage incentive spirometry
Rationale: Incentive spirometry promotes alveolar expansion and
helps prevent atelectasis after surgery.
4. The client reports pain of 8/10 despite using the PCA. What
should the nurse do first?
A. Increase the PCA dose independently
B. Assess the client's respiratory status and sedation level
C. Tell the client to stop using the PCA
D. Administer an oral sedative
Answer: B. Assess the client's respiratory status and sedation level
Rationale: Opioids can cause respiratory depression and excessive
sedation. Safety assessment is required before further opioid
administration.
5. Which finding suggests opioid-induced respiratory depression?
A. HR 106/min
B. RR 8/min with increasing sedation
C. BP 136/78 mm Hg
D. Temperature 37.2°C
Answer: B. RR 8/min with increasing sedation
,Rationale: Bradypnea and increasing sedation are classic warning
signs of opioid-induced respiratory depression.
6. Which action should the nurse take if severe opioid-induced
respiratory depression occurs?
A. Encourage ambulation
B. Hold additional opioid and prepare to administer naloxone as
prescribed
C. Increase the opioid dose
D. Place the client flat and unattended
Answer: B. Hold additional opioid and prepare to administer
naloxone as prescribed
Rationale: Naloxone reverses opioid effects and is used when
clinically significant opioid-induced respiratory depression occurs.
7. Which postoperative finding should the nurse report?
A. Urine output of 35 mL/hr
B. Mild incisional discomfort
C. Urine output of 15 mL/hr for 2 consecutive hours
D. Sleepiness after pain medication
Answer: C. Urine output of 15 mL/hr for 2 consecutive hours
Rationale: Persistently low urine output can indicate inadequate
renal perfusion or another complication and requires evaluation.
8. Which action reduces the risk of catheter-associated urinary tract
infection?
A. Disconnect the drainage tubing daily
B. Keep the drainage bag below bladder level
C. Irrigate the catheter routinely
D. Place the drainage bag on the bed
Answer: B. Keep the drainage bag below bladder level
, Rationale: Keeping the closed drainage system below bladder level
helps prevent urine backflow and infection.
9. Which postoperative intervention should the nurse prioritize?
A. Encourage coughing and deep breathing
B. Provide a television remote
C. Offer a full meal immediately
D. Limit repositioning
Answer: A. Encourage coughing and deep breathing
Rationale: Pulmonary hygiene promotes ventilation and secretion
clearance and reduces postoperative respiratory complications.
10. Which finding indicates possible wound infection?
A. Edges approximated
B. Small amount of serosanguineous drainage
C. Increasing erythema, warmth, and purulent drainage
D. Mild tenderness during the first postoperative day
Answer: C. Increasing erythema, warmth, and purulent drainage
Rationale: Increasing redness, warmth, and purulent drainage are
concerning for infection.
Case Study 2 — Fall Risk
A 79-year-old client is admitted with weakness and dizziness. The
client takes antihypertensive and diuretic medications and reports
two falls at home.
11. Which intervention is most appropriate?
A. Keep all four side rails raised
B. Place the call light within reach
C. Encourage independent bathroom use
D. Keep the room dark
Complete Review: Case
Studies, Rationales & Clinical
Judgment
Postoperative Client
A 68-year-old client is 8 hr postoperative following an abdominal
surgery. The client has an IV infusion, urinary catheter, oxygen at 2
L/min by nasal cannula, and a PCA pump. Vital signs: T 38.1°C
(100.6°F), HR 104/min, RR 24/min, BP 108/64 mm Hg, SpO₂ 92%.
1. Which finding requires the nurse's immediate attention?
A. Temperature of 38.1°C
B. Heart rate of 104/min
C. Respiratory rate of 24/min
D. SpO₂ of 92%
Answer: D. SpO₂ of 92%
Rationale: Oxygenation is the priority because impaired oxygenation
can rapidly become life-threatening. The nurse should assess airway
and breathing and intervene promptly.
2. Which assessment should the nurse perform first?
A. Inspect the surgical incision
B. Assess respiratory effort and breath sounds
C. Check urine output
D. Assess bowel sounds
,Answer: B. Assess respiratory effort and breath sounds
Rationale: The ABC framework prioritizes airway and breathing
before circulation or postoperative gastrointestinal assessment.
3. Which intervention is appropriate for preventing postoperative
atelectasis?
A. Restrict oral fluids
B. Encourage incentive spirometry
C. Maintain strict bed rest
D. Limit coughing
Answer: B. Encourage incentive spirometry
Rationale: Incentive spirometry promotes alveolar expansion and
helps prevent atelectasis after surgery.
4. The client reports pain of 8/10 despite using the PCA. What
should the nurse do first?
A. Increase the PCA dose independently
B. Assess the client's respiratory status and sedation level
C. Tell the client to stop using the PCA
D. Administer an oral sedative
Answer: B. Assess the client's respiratory status and sedation level
Rationale: Opioids can cause respiratory depression and excessive
sedation. Safety assessment is required before further opioid
administration.
5. Which finding suggests opioid-induced respiratory depression?
A. HR 106/min
B. RR 8/min with increasing sedation
C. BP 136/78 mm Hg
D. Temperature 37.2°C
Answer: B. RR 8/min with increasing sedation
,Rationale: Bradypnea and increasing sedation are classic warning
signs of opioid-induced respiratory depression.
6. Which action should the nurse take if severe opioid-induced
respiratory depression occurs?
A. Encourage ambulation
B. Hold additional opioid and prepare to administer naloxone as
prescribed
C. Increase the opioid dose
D. Place the client flat and unattended
Answer: B. Hold additional opioid and prepare to administer
naloxone as prescribed
Rationale: Naloxone reverses opioid effects and is used when
clinically significant opioid-induced respiratory depression occurs.
7. Which postoperative finding should the nurse report?
A. Urine output of 35 mL/hr
B. Mild incisional discomfort
C. Urine output of 15 mL/hr for 2 consecutive hours
D. Sleepiness after pain medication
Answer: C. Urine output of 15 mL/hr for 2 consecutive hours
Rationale: Persistently low urine output can indicate inadequate
renal perfusion or another complication and requires evaluation.
8. Which action reduces the risk of catheter-associated urinary tract
infection?
A. Disconnect the drainage tubing daily
B. Keep the drainage bag below bladder level
C. Irrigate the catheter routinely
D. Place the drainage bag on the bed
Answer: B. Keep the drainage bag below bladder level
, Rationale: Keeping the closed drainage system below bladder level
helps prevent urine backflow and infection.
9. Which postoperative intervention should the nurse prioritize?
A. Encourage coughing and deep breathing
B. Provide a television remote
C. Offer a full meal immediately
D. Limit repositioning
Answer: A. Encourage coughing and deep breathing
Rationale: Pulmonary hygiene promotes ventilation and secretion
clearance and reduces postoperative respiratory complications.
10. Which finding indicates possible wound infection?
A. Edges approximated
B. Small amount of serosanguineous drainage
C. Increasing erythema, warmth, and purulent drainage
D. Mild tenderness during the first postoperative day
Answer: C. Increasing erythema, warmth, and purulent drainage
Rationale: Increasing redness, warmth, and purulent drainage are
concerning for infection.
Case Study 2 — Fall Risk
A 79-year-old client is admitted with weakness and dizziness. The
client takes antihypertensive and diuretic medications and reports
two falls at home.
11. Which intervention is most appropriate?
A. Keep all four side rails raised
B. Place the call light within reach
C. Encourage independent bathroom use
D. Keep the room dark
