ATI RN
Free Medical Surgical Certification Practice Questions Questions
Question 1 of 5
A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Notify Rapid Response Team. Continuous cyanosis despite oxygen therapy after benzocaine spray indicates possible methemoglobinemia, a life-threatening condition. Rapid Response Team can provide immediate intervention and transfer to a higher level of care. Administering albuterol (A) is not indicated for methemoglobinemia. Assessing peripheral pulses (C) may not address the underlying issue. Obtaining blood and sputum cultures (D) is not the priority in this acute situation.
Question 2 of 5
After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?
Correct Answer: D
Rationale: The correct answer is D because tracheal deviation indicates a potential tension pneumothorax, a life-threatening emergency requiring immediate intervention. Tracheal deviation occurs when there is a significant shift in the mediastinum due to increased pressure in the pleural space. This can compromise respiratory function and lead to respiratory failure. Options A, B, and C are not as urgent as tracheal deviation. Pain at 5/10 is expected post-thoracentesis, a small amount of drainage is common, and a pulse oximetry reading of 93% on low oxygen is concerning but not immediately life-threatening.
Question 3 of 5
A client had a bronchoscopy 2 hours ago and asks for a drink of water. Which action should the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Assess the client's gag reflex before giving any food or water. After a bronchoscopy, the client may have an impaired gag reflex due to the numbing agent used during the procedure. Assessing the gag reflex is crucial to prevent aspiration and ensure the client can safely swallow without the risk of choking or inhaling fluids. This step is essential before offering any food or water to the client. Option A is incorrect because calling the healthcare provider for a prescription is unnecessary at this point. Option B is incorrect because ice chips can still pose a risk if the client's gag reflex is impaired. Option D is incorrect as allowing the client to have a sip without assessing the gag reflex first could lead to complications if the client is unable to swallow properly.
Question 4 of 5
A client with dyspnea and difficulty climbing stairs is classified as having class III dyspnea. Which intervention should the nurse include in the client's plan of care?
Correct Answer: A
Rationale: The correct answer is A: Assistance with activities of daily living. Class III dyspnea signifies moderate exertion causing symptoms. Therefore, the client may need help with daily activities to conserve energy. Daily physical therapy (B) may be too strenuous. Oxygen therapy (C) may not be necessary at this point. Complete bedrest (D) can lead to deconditioning.
Question 5 of 5
When assessing a client with pneumonia, which clinical manifestation should the nurse expect to find?
Correct Answer: C
Rationale: The correct answer is C: Dullness on percussion. In pneumonia, the affected lung tissue becomes consolidated, leading to dullness on percussion due to decreased air movement. The rationale behind this is that consolidation causes the air-filled lung tissue to become filled with fluid and inflammatory cells, impairing normal sound transmission upon percussion. Incorrect choices: A: Fremitus - Increased tactile fremitus is typically found in pneumonia due to the denser lung tissue, making this choice incorrect. B: Hyperresonance - Hyperresonance is commonly found in conditions like emphysema with increased lung air volume, not in pneumonia. D: Decreased tactile fremitus - This is contradictory as pneumonia usually presents with increased tactile fremitus due to the consolidated lung tissue.