ATI LPN
Critical Care Respiratory Questions Questions
Question 1 of 5
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
Correct Answer: D
Rationale: Contact precautions. Major wound infections require contact precautions.
Question 2 of 5
The nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client’s vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
Correct Answer: D
Rationale: Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status, therefore the next action is to activate the chain of command to ensure the client receives care.
Question 3 of 5
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Pad the client’s wrist before applying the restraints. The nurse should evaluate the client’s circulation every 15 min, the nurse should remove the restraints every 2 hr to reposition, the nurse should remove and assess needs for hygiene, the nurse should secure the restraint ties to a part of the bed frame that moves with the client.
Question 4 of 5
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: Abdominal cramping. Low sodium level manifests as cramping, weakness, confusion, and lethargy. Chvostek’s sign is a manifestation of hypomagnesemia and hypocalcemia. Tachycardia is a manifestation of hyponatremia along with hypovolemia.
Question 5 of 5
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
Correct Answer: C
Rationale: It might help me to listen to music while I’m lying in bed.