ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 16 Questions
Question 1 of 5
A postoperative client is being assessed in the postanesthesia care unit (PACU). Which assessment takes priority?
Correct Answer: A
Rationale: Assessing the airway always takes priority, followed by breathing and circulation. Bleeding and cardiac rhythm are part of the circulation assessment, but airway patency is the most critical in the immediate postoperative period.
Question 2 of 5
A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the client's plan of care to minimize the potential for this occurring? (Select all that apply.)
Correct Answer: A,B,C,E
Rationale:
To minimize confusion, the nurse should encourage familiar visitors, assess coping techniques, maintain hygiene, and ensure adequate sleep. Secluding the client may increase sensory deprivation and confusion.
Question 3 of 5
A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?
Correct Answer: C
Rationale: The safety pin that prevents the drain from slipping back into the client's body should be pinned to the client's gown, not the bedding. Pinning it to the sheets could cause the drain to pull out when the client moves. The other actions are appropriate.
Question 4 of 5
A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort measures can the nurse provide? (Select all that apply.)
Correct Answer: A,B,C,D
Rationale: Nonpharmacologic measures like contralateral stimulation, meditation, leg elevation with ice, and reducing environmental noise can help manage pain. Loud TV is not an effective diversion and may increase discomfort.
Question 5 of 5
A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?
Correct Answer: B
Rationale: Before assessing or treating drainage from the wound, the nurse must perform hand hygiene and don gloves to protect both the client and nurse from infection, adhering to standard precautions.