ATI LPN
Perioperative Nursing Care Questions Questions
Question 1 of 5
A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 of 5
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?
Correct Answer: A
Rationale: The Mantoux test, used to screen for tuberculosis exposure, requires precise administration to ensure accurate results. It involves injecting purified protein derivative (PPD) intradermally into the inner forearm, creating a small wheal just under the skin surface. This method targets the dermal layer where immune cells can react to the antigen, producing a measurable induration if the child has been exposed to TB. Intramuscular injections into the vastus lateralis or subcutaneous injections into the umbilical area or deltoid are inappropriate because they deliver the substance too deeply or into fatty tissue, preventing the localized skin reaction needed for interpretation. The intradermal technique, typically at a 5-15 degree angle with a fine needle, ensures the PPD remains in the dermis, maximizing sensitivity and specificity of the test, which is critical for early detection in a pediatric population.
Question 3 of 5
The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patients symptoms from those of a cardiac etiology?
Correct Answer: B
Rationale: In early ARDS, distinguishing respiratory failure from cardiac causes like congestive heart failure (CHF) is crucial, and brain natriuretic peptide (BNP) levels are the most likely test ordered. Elevated BNP, secreted by the heart under strain, indicates cardiac etiology (e.g., pulmonary edema from CHF), whereas normal or low BNP supports ARDS, a non-cardiogenic lung injury with alveolar flooding. Carboxyhemoglobin measures carbon monoxide poisoning, relevant to inhalation injury but not routine for ARDS differentiation. CRP reflects inflammation, common in both ARDS and infection, but lacks specificity for cardiac versus pulmonary origin. A complete blood count provides general health data (e.g., infection) but doesn't pinpoint etiology. BNP, often paired with echocardiography, guides the nurse and team to tailor treatment ventilation for ARDS versus diuretics for CHF ensuring accurate early management of this critical condition.
Question 4 of 5
The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing?
Correct Answer: C
Rationale: Right-sided chest pain worsening with coughing or deep breathing in an 82-year-old with tracheobronchitis suggests pleuritic pain, likely from pleural inflammation secondary to the airway infection. Pleurisy's hallmark is sharp, movement-exacerbated pain due to irritated pleural surfaces rubbing together, often unilateral, and may decrease as fluid accumulates later. Stable vital signs rule out severe systemic issues. Traumatic pneumothorax requires injury, absent here, and would show respiratory distress or absent breath sounds. Empyema, a pleural infection, typically involves fever and systemic signs, not just pain, and isn't indicated without infection escalation. Myocardial infarction causes central, pressure-like pain, often with vital sign changes (e.g., tachycardia, hypotension), not pleuritic features. The nurse's suspicion of pleuritic pain prompts pain management and monitoring for progression, aligning with tracheobronchitis complications.
Question 5 of 5
A patient with emphysema is experiencing shortness of breath. To relieve this patients symptoms, the nurse should assist her into what position?
Correct Answer: A
Rationale: For an emphysema patient with shortness of breath, sitting upright and leaning forward slightly optimizes respiratory mechanics. This position, often instinctive in COPD, elevates the diaphragm, reducing its flattening from hyperinflation, and engages accessory muscles (e.g., pectoralis) to aid expiration, easing dyspnea. Leaning forward may also reduce abdominal pressure on the thorax, enhancing lung expansion. Low Fowler's with neck hyperextension strains breathing by misaligning the airway and limiting diaphragm movement. Prone positioning, face-down, restricts chest expansion, worsening air trapping. Trendelenburg, head-down, elevates abdominal contents against the diaphragm, intensifying dyspnea. The nurse's assistance into this upright, forward-leaning posture often with arms supported maximizes ventilation, aligning with COPD management to relieve acute respiratory distress effectively.