ATI RN
ATI RN Custom Med Surg Surgical patient Questions
Question 1 of 5
A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?
Correct Answer: D
Rationale: Covering the protruding bowel with a moist, sterile dressing prevents dehydration and infection. Vital signs, informing the client, and positioning are secondary to protecting the bowel.
Question 2 of 5
A nurse is providing care to a group of patients in an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?
Correct Answer: C
Rationale: Enteral feedings via NG tube increase aspiration risk due to impaired swallowing and potential tube misplacement. Colostomies and ileostomies affect lower digestive tracts, and chest tubes address pleural issues, not aspiration.
Question 3 of 5
A nurse on a medical-surgical unit is caring for a patient who is also a hospital employee. Several nurses have called seeking information about the patient. What should the nurse do in response to these inquiries?
Correct Answer: C
Rationale: Acknowledging the patient's presence without disclosing specific details balances privacy with transparency. It adheres to HIPAA by limiting information to a need-to-know basis. Referring to the supervisor may delay responses and overburden them. Transferring calls breaches privacy without patient consent. Contacting the provider is inefficient for handling inquiries.
Question 4 of 5
A nurse is caring for a patient on a medical-surgical unit who is attempting to leave the facility. What action should the nurse take?
Correct Answer: D
Rationale: Ensuring the patient understands they are leaving against medical advice respects their autonomy while fulfilling the nurse's duty to inform them of risks. This involves documenting the decision and having the patient sign an AMA form. Notifying security escalates the situation prematurely. Calling family may breach confidentiality without consent. Insisting on a wheelchair is unnecessary unless safety is a concern.
Question 5 of 5
A nurse is caring for a patient on the third day following abdominal surgery. The nurse notes the absence of bowel sounds, abdominal distention, and the patient has not passed any flatus. Which postoperative complication is the patient likely experiencing?
Correct Answer: A
Rationale: Paralytic ileus is a common postoperative complication characterized by slowed or stopped intestinal peristalsis, leading to gas and fluid buildup, causing abdominal distention, nausea, and constipation. The absence of bowel sounds, distention, and lack of flatus are hallmark signs. Incisional infection presents with localized symptoms like redness and pain at the incision site. Fecal impaction involves a hard stool mass in the rectum, not typically linked to absent bowel sounds. Clostridium difficile infection causes diarrhea, not the symptoms described.