ATI RN
Care of Patients with Shock Practice Questions Questions
Question 1 of 5
A 17-year-old boy develops pulmonary edema after resolution of postoperative laryngospasm. While breathing 100% O2, SpO2 is 80%. Which of the following strategies is the MOST appropriate management?
Correct Answer: C
Rationale: Pulmonary edema from negative pressure (post-laryngospasm) requires positive-pressure ventilation to improve oxygenation and reduce fluid in the alveoli.
Question 2 of 5
The nurse and the nursing assistive personnel are assisting a postoperative patient to turn in bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient?
Correct Answer: D
Rationale: The correct answer is D: "Place your hand over your incision." This instruction is correct because it encourages the patient to provide support and gentle pressure to the incision area while turning, which can help reduce discomfort and provide a sense of security. This action can also prevent accidental disruption of the incision site. A: "Close your eyes and think about something pleasant." This choice does not provide any physical support or guidance for the patient during the turning process. B: "Hold your breath and count to three." This instruction is incorrect as holding one's breath can increase intra-abdominal pressure and potentially cause discomfort during the turning maneuver. C: "Grab my shoulders with your hands." This choice does not address the specific need to provide support to the incision area and may not be the most effective way to minimize discomfort during turning.
Question 3 of 5
Which of the following conditions is most likely to cause a patient to present with potentially reversible pulseless electrical activity on the monitor?
Correct Answer: D
Rationale: Pulseless electrical activity (PEA) is a state of organized electrical activity without a palpable pulse. Tension pneumothorax can cause PEA by impairing cardiac output due to increased intrathoracic pressure. This leads to inadequate blood flow and results in PEA. Traumatic asphyxia causes petechial hemorrhages but not PEA. Wolf Parkinson White syndrome is characterized by accessory pathways in the heart, not directly linked to PEA. The R-on-T phenomenon refers to a premature ventricular contraction falling on the T wave, which can cause ventricular arrhythmias but not PEA.
Question 4 of 5
You suspect your unconscious adult trauma patient may have increased intracranial pressure from a closed head injury. Due to the compression forces of increased intracranial pressure, at what level of brain injury would be expected if the patient is exhibiting Cheyne-Stokes respirations and is presenting with increasing blood pressure readings and a decreasing, reactive pulse rate?
Correct Answer: A
Rationale: The correct answer is A: Cortex and upper brainstem. When a patient with increased intracranial pressure exhibits Cheyne-Stokes respirations, increasing blood pressure, and decreasing, reactive pulse rate, it indicates dysfunction at the level of the cortex and upper brainstem. Cheyne-Stokes respirations are associated with damage at the level of the cortex. Increasing blood pressure and decreasing, reactive pulse rate are signs of raised intracranial pressure affecting the upper brainstem. Dysfunction at the midbrain region or lower portion of the brainstem would present with different symptoms, such as pinpoint pupils or abnormal posturing. The medulla oblongata is responsible for controlling vital functions like breathing and heart rate, so dysfunction in this region would present with more severe respiratory and cardiovascular symptoms.
Question 5 of 5
You suspect your adult trauma patient has a potential complete spinal cord transection. If so, which of the following would you expect to find?
Correct Answer: C
Rationale: The correct answer is C because a complete spinal cord transection results in total absence of pain, sensation, and movement below the point of injury due to the interruption of all nerve pathways. This is known as complete paralysis. Choices A and D describe incomplete injuries, where some function is preserved. Choice B is incorrect as bradycardia and loss of vascular tone are associated with injuries at higher spinal cord levels, such as cervical injuries, not complete transections.