ATI RN
Free Medical Surgical Certification Practice Questions Questions
Question 1 of 5
A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?
Correct Answer: C
Rationale: The correct question to ask first is C: "Do you experience shortness of breath with basic activities?" This is because shortness of breath is a common and concerning symptom in COPD patients that can greatly impact their quality of life and indicate disease progression. By addressing this symptom first, the nurse can assess the severity of the client's condition and determine the immediate need for intervention or treatment. Asking about support system (A) is important but not as urgent as addressing the primary symptom. Inquiring about the client's understanding of the disease (B) and medications (D) is also important but should come after addressing the immediate symptom of shortness of breath.
Question 2 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 3 of 5
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?
Correct Answer: A
Rationale: The correct answer is A: Assess the client's oxygen saturation. This is the priority because the client's puffy face and swollen eyelids may indicate airway obstruction or respiratory distress, common complications in tracheostomy patients. Assessing oxygen saturation helps determine if the client is getting enough oxygen. Option B (Notify the Rapid Response Team) is not the immediate action unless the client's condition deteriorates rapidly. Option C (Oxygenate the client with a bag-valve-mask) may be necessary but should come after assessing oxygen saturation. Option D (Palpate the skin of the upper chest) is irrelevant to the client's current symptoms.
Question 4 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 5 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.