A client is scheduled for a cholecystectomy in the morning. In planning the postoperative care, the priority nursing diagnosis for the client will be at high-risk for:

Correct Answer: D

Rationale: The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a postoperative priority nursing diagnosis. The client will have a Foley catheter for a day or two after the surgery. Urinary retention is usually not a problem once the Foley catheter is removed. A client having a cholecystectomy should not be physically impaired. The client is encouraged to begin ambulating soon after surgery. Because of the location of the incision, the cholecystectomy client is reluctant to breath deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.

Correct Answer: C

Rationale: In this scenario, the correct nursing action is to have the student breathe into a paper bag (Option C). This is because the symptoms described indicate possible hyperventilation, which can lead to respiratory alkalosis. Breathing into a paper bag helps to rebreathe exhaled carbon dioxide, which can help restore the acid-base balance in the body. Option A (Notify the physician immediately) is incorrect because the situation does not warrant immediate physician notification as it is a common nursing intervention that can be implemented without a physician's order. Option B (Administer supplemental oxygen) is incorrect because supplemental oxygen is not indicated for hyperventilation. In fact, giving oxygen may worsen the respiratory alkalosis by decreasing carbon dioxide levels further. Option D (Obtain an order for an anxiolytic medication) is also incorrect because the priority in this situation is to address the respiratory alkalosis caused by hyperventilation, not anxiety. Anxiolytic medications are not the first-line treatment for hyperventilation. In an educational context, understanding the rationale behind interventions for respiratory alkalosis is crucial for nurses caring for patients experiencing this condition. Nurses need to recognize the signs and symptoms of respiratory alkalosis and implement appropriate nursing interventions promptly to restore the acid-base balance in the body. This knowledge is essential for providing safe and effective patient care in various clinical settings.

Correct Answer: B

Rationale: In the management of status epilepticus, the drug of choice for immediate administration is a benzodiazepine, such as IV lorazepam (Ativan). This is because benzodiazepines have a rapid onset of action and are effective in terminating seizure activity quickly. Lorazepam is preferred over phenytoin or carbamazepine because these drugs have a slower onset of action and are not suitable for acute seizure management. Option A (PO phenytoin and carbamazepine) is incorrect because oral medications are not appropriate for managing status epilepticus due to their slow absorption and onset of action. IV carbamazepine (Option C) is also not recommended for the acute management of seizures because it has a delayed onset of action. IV magnesium sulfate (Option D) is used for certain types of seizures like eclampsia but is not the first-line drug for status epilepticus. In an educational context, it is crucial for healthcare providers to understand the appropriate pharmacological interventions for emergency situations like status epilepticus. Knowing which medications to administer promptly can help prevent complications and improve patient outcomes. Understanding the rationale behind choosing a specific drug over others is essential for safe and effective clinical practice.

Correct Answer: A

Rationale: In the context of the ATI Medical Surgical Proctored Exam, the priority nursing diagnosis among the options provided is A) Risk for Injury related to seizures. This is the correct answer because seizures pose an immediate threat to the patient's physical safety and well-being. Seizures can lead to injuries such as falls, head trauma, and other complications that require prompt nursing intervention to prevent harm. Option B) Risk for Other-Directed Violence related to hallucinations is not the priority in this case because the patient's safety is at a higher risk due to seizures, which are more directly life-threatening. Option C) Risk for Situational Low Self-esteem related to police custody and Option D) Risk for Nutritional Deficit related to chronic alcohol abuse are also important nursing diagnoses to address in the overall care of the patient. However, in the immediate context of ensuring the patient's safety and preventing harm, addressing the risk for injury related to seizures takes precedence. From an educational perspective, understanding the concept of prioritizing nursing diagnoses based on the urgency of the patient's needs is crucial for nursing practice. Nurses must be able to quickly assess and prioritize patient care to address the most critical issues first to ensure patient safety and well-being. This rationale highlights the importance of critical thinking and clinical judgment in determining the priority of care for patients in various healthcare scenarios.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) A deviated trachea. A deviated trachea is a critical assessment finding that signals a potentially life-threatening condition such as tension pneumothorax or a large mediastinal mass. A deviated trachea indicates a shift in the mediastinum, which can compromise airway patency and lead to respiratory distress. Option B) Gross deformity in a lower extremity is typically associated with musculoskeletal injuries, which are serious but not immediately life-threatening unless there is severe vascular compromise. Option C) Decreased breath sounds can indicate conditions such as atelectasis or pleural effusion, which are significant but may not be as acutely life-threatening as a deviated trachea. Option D) Hemoptysis, while concerning for conditions like pulmonary embolism or malignancy, may not always indicate an immediate life-threatening situation compared to a deviated trachea. Educationally, understanding the significance of assessment findings in prioritizing care is crucial for nurses in providing timely interventions to prevent further deterioration in a patient's condition. Recognizing the urgency of a deviated trachea can prompt swift action and potentially save a patient's life.