ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
Correct Answer: B
Rationale: The correct answer is B: Stridor. Stridor is a high-pitched, inspiratory sound that indicates upper airway obstruction and impending respiratory distress, which is a life-threatening complication of anaphylaxis. The nurse should intervene first by ensuring a patent airway to prevent respiratory compromise. Urticaria (A) is a common symptom of an allergic reaction but does not pose an immediate threat to airway patency. Vomiting (C) can be a sign of gastrointestinal distress but does not require immediate intervention for airway protection. Hypotension (D) is a serious manifestation of anaphylaxis but addressing airway obstruction takes precedence to prevent respiratory failure.
Question 2 of 5
A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Step 1: Recognize potential complications of femur fracture - fat embolism syndrome (FES) can cause sudden onset dyspnea and chest pain. Step 2: Provide high-flow oxygen to improve oxygenation and stabilize the client's condition. Step 3: Oxygen therapy takes priority to address potential respiratory compromise and prevent further deterioration. Summary: - Option B (Chvostek's sign) is unrelated to the client's current symptoms. - Option C (IV vasopressor) is not indicated for FES. - Option D (monitor for headache) is not a priority when the client is experiencing dyspnea and chest pain.
Question 3 of 5
A nurse in the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Movement of the ET tube into the right main bronchus. When the nurse observes absence of left-sided chest wall expansion, it indicates that the ET tube may have moved into the right main bronchus. This can lead to inadequate ventilation of the left lung, causing unilateral chest wall expansion. The other choices are incorrect because: A) Blockage by the tongue would not result in unilateral chest wall expansion. B) Passage into the esophagus would lead to improper ventilation but not specifically affect one side of the chest. D) Infection of the vocal cords would not directly cause unilateral chest wall expansion.
Question 4 of 5
When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct action is to administer the abdominal thrust maneuver (Heimlich maneuver) first to attempt to dislodge the foreign body. This is the priority intervention when a conscious client is experiencing airway obstruction. Inserting an oral airway (Choice A) may worsen the obstruction. Turning the client to the side (Choice C) does not directly address the airway obstruction. Performing a blind finger sweep (Choice D) is not recommended as it can push the object further down the airway. Administering the abdominal thrust maneuver is the most effective and safest initial intervention to clear the airway obstruction.
Question 5 of 5
The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
Correct Answer: A
Rationale: The correct answer is A: Evaluate chest expansion. This is the priority action because it assesses the client's airway and breathing, which are critical for survival. Checking chest expansion helps to identify any potential respiratory compromise or underlying lung injuries. Assessing pupillary response (B) and capillary refill (C) are important, but they are secondary to ensuring adequate oxygenation. Checking the client's orientation to place and time (D) is important for neurological assessment but is not as critical as assessing airway and breathing in this scenario.