ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?
Correct Answer: A
Rationale: The correct answer is A: Airway protection. The priority focus of care in a client with multiple system trauma is to ensure a patent airway to maintain oxygenation and ventilation. Without a clear airway, the client can rapidly deteriorate. Airway management takes precedence over other interventions to prevent hypoxia and respiratory failure. Decreasing intracranial pressure (B) and stabilizing cardiac arrhythmias (C) are important but secondary to ensuring adequate oxygenation. Preventing musculoskeletal disability (D) is not the immediate concern in this critical situation.
Question 2 of 5
A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?
Correct Answer: A
Rationale: The correct answer is A: Respiratory acidosis. Shallow respirations at 9/min indicate hypoventilation, leading to retention of CO2 and respiratory acidosis. This is because inadequate removal of CO2 results in an increase in carbonic acid concentration, leading to a decrease in blood pH. Respiratory alkalosis (B) is unlikely with shallow respirations. Metabolic acidosis (C) results from nonrespiratory factors. Metabolic alkalosis (D) is not related to respiratory rate.
Question 3 of 5
A client with acute respiratory distress syndrome (ARDS) requires care planning. Which of the following interventions should be included in the plan?
Correct Answer: D
Rationale: The correct answer is D, placing the client in a prone position. This intervention optimizes oxygenation by improving ventilation-perfusion matching in ARDS. When the client is in a prone position, there is better distribution of ventilation to the dorsal lung regions, reducing the risk of ventilator-induced lung injury. Choice A is incorrect because low-flow oxygen may not be sufficient to meet the oxygen demands of a client with ARDS. Choice B is incorrect because excessive oral intake can lead to fluid overload in ARDS. Choice C is incorrect because high-protein and high-carbohydrate foods may be difficult for the client to tolerate and can contribute to increased carbon dioxide production.
Question 4 of 5
A client has developed atelectasis postoperatively. Which of the following findings should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Increasing dyspnea. Atelectasis is a condition where the lung tissue collapses, leading to decreased oxygen exchange and resulting in symptoms like dyspnea (difficulty breathing). This occurs because the collapsed lung tissue reduces the surface area available for gas exchange, leading to decreased oxygen saturation and increased work of breathing. Facial flushing (choice A) is not typically associated with atelectasis. Decreasing respiratory rate (choice C) may not be a reliable indicator as the body may compensate by increasing respiratory rate to maintain oxygenation. Friction rub (choice D) is more commonly associated with conditions like pleurisy or pneumonia, not atelectasis.
Question 5 of 5
A healthcare professional is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the healthcare professional anticipate administering?
Correct Answer: C
Rationale: The correct answer is C: Heparin. Heparin is a common anticoagulant used to prevent further clotting in patients with pulmonary embolism. It works by inhibiting blood clot formation. Furosemide (A) is a diuretic used for conditions like heart failure and edema, not for pulmonary embolism. Dexamethasone (B) is a corticosteroid used for inflammation and immune suppression, not for pulmonary embolism. Atropine (D) is used to treat bradycardia and not indicated for pulmonary embolism. Administering heparin is crucial to prevent worsening of the pulmonary embolism and potential life-threatening complications.