ATI RN
Free Medical Surgical Certification Practice Questions Questions
Question 1 of 5
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
Correct Answer: B
Rationale: The correct answer is B: Ensure informed consent is on the chart. This is the priority because obtaining informed consent is essential to ensure the client understands the procedure, risks, benefits, and alternatives. It protects the client's autonomy and ensures legal and ethical standards are met. Administering anxiolytic medication may help with anxiety but does not address the crucial issue of consent. Reinforcing teaching and starting antibiotics are important but secondary to obtaining informed consent.
Question 2 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 3 of 5
A client with a tracheostomy experienced a coughing spell during a meal that was being fed by an unlicensed assistive personnel (UAP). What action by the nurse takes priority?
Correct Answer: A
Rationale: The correct answer is A: Assess the client's lung sounds. This action takes priority because the client experienced a coughing spell, indicating a potential aspiration risk. Assessing lung sounds can help determine if there is any respiratory distress or compromised airway. B: Assigning a different UAP does not address the immediate concern of the client's respiratory status. C: Reporting the UAP to the manager may be necessary but is not the immediate priority when the client's health is at risk. D: Requesting thicker liquids for meals does not address the client's current condition and may not be appropriate without proper assessment.
Question 4 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 5 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.