ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 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 2 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 3 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.
Question 4 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 5 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.