ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
A 72-year-old female client is lifted to the surgery table in preparation for a total knee replacement. The client is in stage III of inhalation anesthesia. An appropriate nursing action for this client is:
Correct Answer: B
Rationale: Preventing injury by restraining the client, if necessary, is a nursing action of stage II, which extends from loss of consciousness to relaxation. Stage III extends from the loss of lid reflex to cessation of voluntary respirations. Operative procedures are performed during stage III of inhalation anesthesia. Promoting restoration of ventilation and vasomotor tone is a nursing action for stage IV in which an overdose has occurred. Respiratory arrest and vasomotor collapse result from medullary paralysis. Reduction of external stimuli is a nursing action for stage I, which extends from induction to loss of consciousness.
Question 2 of 5
A client returns to the Cardiovascular Intensive Care Unit following a coronary artery bypass graft (CABG). In planning the client's care, the most important electrolyte to monitor is:
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
A postoperative priority nursing diagnosis for a client having a vertical partial laryngectomy would be:
Correct Answer: B
Rationale: The laryngectomy client should be able to gradually increase activities without difficulty. The laryngectomy client may have copious amounts of secretions, which will require suctioning for the first 24-48 hours. Because the mucous collects in the cannula, it will require cleaning after the first 24 hours. Even though the client does have a potential for infection, this is not more important than the ineffective airway clearance. An altered mucous membrane problem is not more important than ineffective airway clearance. The client's mouth may become dry, but can be taken care of with good oral care.
Question 4 of 5
A 29-year-old client is admitted for a hysterectomy and is expressing concern regarding the procedure. Shortly into the preoperative teaching, the client complains of a tightness in the chest, feelings of suffocation, light-headedness, and tingling in the hands. The client's respirations are rapid and deep. The nursing assessment reveals that this client is:
Correct Answer: D
Rationale: Classic symptoms of a heart attack include a heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may also be present. However, the client does not exhibit these symptoms. Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. Symptoms of complete airway obstruction include not being able to speak, lack of airflow between the nose and mouth, and absent breath sounds. A tightness in the chest, feelings of suffocation, light-headedness, tingling in the hands, and rapid deep respirations are signs and symptoms of hyperventilation, which is almost always a manifestation of anxiety.
Question 5 of 5
Trevor Gilbert, 59, arrives at the ambulatory surgery department as instructed prior to his back surgery. The baseline history taken on Mr. Gilbert should include:
Correct Answer: D
Rationale: A preoperative assessment should include the patient's history, but the focus should be particularly on his expectations of this particular hospitalization. Knowledge about whether he received his childhood immunizations is important, but his reactions to those, even if he knows what they were, is not the most important information to gain today. The type of diet he's on is good information, but again not the most important information listed here. It is vital to determine the patient's expectations of his surgery, in order to correct any misperceptions he may have about the outcome, or reason, for this invasive treatment.