ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 16 Questions
Question 1 of 5
A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?
Correct Answer: D
Rationale: Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.
Question 2 of 5
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?
Correct Answer: C
Rationale: The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or is a postoperative client. A respiratory rate of 8 breaths/min is abnormally low and requires immediate assessment. The other vital signs, while concerning, are less critical in this context.
Question 3 of 5
A postoperative client states that the sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?
Correct Answer: D
Rationale: According to the Surgical Care Improvement Project (SCIP), prophylactic measures to prevent thrombembolic events, such as sequential compression devices, are continued for 24 hours after surgery. The nurse should explain this to the client to promote compliance. Calling the surgeon is unnecessary, and simply refusing or agreeing to remove them does not address the client's concerns or provide education.
Question 4 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 5 of 5
A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which medication and dose does the nurse prepare to administer?
Correct Answer: A
Rationale: Flumazenil is a benzodiazepine antagonist used to reverse the effects of midazolam. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist and would not be appropriate for reversing benzodiazepine-induced respiratory depression.