ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 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 2 of 5
A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?
Correct Answer: B
Rationale: The correct answer is B: Count the respiratory rate. This is the priority intervention because anaphylaxis can lead to severe respiratory distress due to airway swelling or bronchoconstriction. Counting the respiratory rate helps to quickly assess the client's breathing status and detect any signs of respiratory distress. Inserting an IV line (choice A) may be necessary for administering medications, but assessing the respiratory rate takes precedence. Administering oxygen (choice C) is important but should follow assessing the respiratory rate. Preparing equipment for intubation (choice D) is a later intervention if respiratory distress worsens.
Question 3 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 4 of 5
During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
Correct Answer: A
Rationale: The correct answer is A because Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea. This pattern reflects an abnormal breathing cycle that is often seen in end-of-life care or in patients with severe neurological problems. Choice B is incorrect because it describes a pattern of shallow to normal breaths alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations. Choice C is incorrect as it describes rapid respirations that are unusually deep and regular, which is not consistent with the pattern of Cheyne-Stokes respirations. Choice D is also incorrect because it describes an inability to breathe without dyspnea unless sitting upright, which is not a characteristic of Cheyne-Stokes respirations.
Question 5 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.