ATI RN
Free Medical Surgical Certification Practice Questions Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
Correct Answer: B
Rationale: The correct answer is B because joining a book club indicates the client is engaging in social activities and pursuing interests, which can boost self-esteem. Choice A focuses on physical care, not self-esteem. Choice C involves family support, not necessarily self-esteem. Choice D only addresses physical health, not emotional well-being. Overall, engaging in social activities promotes self-worth and a sense of belonging, aligning with the goal of improving self-esteem.