ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 31 Questions
Question 1 of 5
Based on the objective and subjective assessment of this patient, which priority problem should the nurse identify to guide the perioperative plan of care?
Correct Answer: C
Rationale: Gabrielle's calm but cooperative behavior, coupled with her reluctance to let go of her mother, indicates acute anxiety as the priority problem. Addressing anxiety is critical to ensure a smooth perioperative experience, as it can impact cooperation and emotional readiness for surgery.
Question 2 of 5
Which solution is reasonable and safe for this transition of care?
Correct Answer: B
Rationale: Allowing Gabrielle's mother to accompany her to the surgical suite until anesthesia takes effect is a safe and reasonable solution. It provides comfort and reduces anxiety during the transition, while ensuring clinical safety under controlled conditions.
Question 3 of 5
Which content and teaching modality best fit this particular situation?
Correct Answer: A
Rationale: Teaching Gabrielle to use the incentive spirometer with direction and encouragement is the most appropriate content and modality. It prepares her for postoperative respiratory exercises to prevent complications, is age-appropriate, and involves both her and her mother in the learning process.
Question 4 of 5
The nurse documents attainment of expected outcomes in the preoperative phase as part of the perioperative plan of care. Which outcomes were met for Gabrielle? Select all that apply.
Correct Answer: B,D,E
Rationale: Gabrielle's nervous but smiling response indicates physical and emotional readiness (
B). The scenario implies her mother was engaged in discussions about postoperative care, suggesting caregiver articulation of follow-up needs (
D). Pulse oximetry >98% on room air (E) is a standard preoperative outcome, assumed met given no contrary indications.
Question 5 of 5
A nurse in the PACU is preparing to receive a patient from surgery who sustained a ruptured spleen in a motor vehicle accident. Which of these system assessments will take priority?
Correct Answer: B
Rationale: The priority assessment focuses on the ruptured organ, blood loss, and monitoring for early signs of shock. Tachycardia, the first sign of shock, and decreasing blood pressure must be immediately reported to the health care provider. The neurologic system may be affected due to anesthesia, but ambulatory function is not the immediate priority. The nurse anticipates reduced or absent bowel sounds after surgery, but risk for blood loss is the priority. The nurse plans to promote wound healing and repositions the patient to prevent skin breakdown; however, hemorrhage and early detection of shock is the priority at this time.