ATI RN
Free Medical Surgical Certification Practice Questions Questions
Question 1 of 5
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Tracheostomy cuff should be inflated to prevent aspiration. 2. Food particles indicate cuff leakage. 3. Measuring cuff pressure ensures proper sealing. 4. Prevents aspiration and respiratory complications. Summary: A: Elevating the head is beneficial but doesn't address cuff leakage. C: NPO status is extreme and unnecessary without confirmation of aspiration risk. D: Swallow study is for assessing swallowing function, not related to cuff pressure.
Question 2 of 5
A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?
Correct Answer: C
Rationale: The correct answer is C: Tying a square knot at the back of the neck. The reason this action requires intervention is that a square knot is not recommended for securing tracheostomy ties as it can be difficult to untie in an emergency. Instead, a quick-release knot or Velcro closure is typically used for easy removal. A: Holding the device securely when changing ties is important for maintaining the integrity of the tracheostomy. B: Suctioning the client first if secretions are present is a standard practice to ensure clear airways. D: Using half-strength peroxide for cleansing is appropriate for tracheostomy care to prevent infection. In summary, the incorrect choice is C because tying a square knot can pose risks in an emergency situation, while the other choices are appropriate actions in tracheostomy care.
Question 3 of 5
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
Correct Answer: A
Rationale: The correct answer is A. When suctioning a tracheostomy, the student should not apply suction while withdrawing the catheter to prevent mucosal damage. The correct technique involves inserting the catheter without applying suction, then withdrawing it while applying suction. This helps to clear secretions effectively without causing trauma. Choices B, C, and D are incorrect. Preoxygenating the client is a recommended practice to prevent hypoxemia during suctioning. Suctioning up to three times if necessary and suctioning for 10-15 seconds each time are appropriate techniques to clear secretions effectively without causing harm.
Question 4 of 5
While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?
Correct Answer: B
Rationale: The correct answer is B because intact skin behind the ears indicates proper oxygen delivery, ensuring the client's respiratory needs are being met. This assessment finding shows that the oxygen therapy is effective in improving oxygenation. A: This choice is incorrect as the client's meal intake does not directly reflect the effectiveness of oxygen therapy. C: Although important, the client's understanding of the need for oxygen does not directly indicate the success of the oxygen therapy. D: Unchanged weight is not a direct indicator of the effectiveness of oxygen therapy in this situation.
Question 5 of 5
While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Stay with the client and ask someone else to contact the provider immediately. Rationale: 1. Pulsation of the tracheostomy tube with heartbeat indicates the tube is very close to a major blood vessel. 2. Immediate provider notification is crucial to prevent potential complications. 3. Removing the tube without professional guidance can lead to severe bleeding and airway compromise. 4. Contacting the provider promptly ensures timely intervention and appropriate next steps. Summary: A: Notifying the operating room is premature and unnecessary at this point. B: Pulsation may not always be normal and warrants immediate action. C: Removing the tube without professional guidance can be harmful to the client.