ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Step 1: Checking the oximeter is essential to assess the client's oxygen saturation levels immediately post-procedure. Step 2: Hypoxia can lead to serious complications, impacting the client's neurological status. Step 3: The nurse must prioritize oxygenation status to prevent further brain injury or hypoxemia. Step 4: Observing for CSF leaks, assessing temperature, and monitoring ICP are important but not as immediate as ensuring adequate oxygen supply. Summary: Option C is correct as it addresses the most critical and immediate concern post-procedure, ensuring optimal oxygenation for the client's neurological recovery. Options A, B, and D are important but secondary to maintaining oxygen levels.
Question 2 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 3 of 5
A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?
Correct Answer: B
Rationale: The correct answer is B: "Keep wire cutters with you at all times." This is the priority statement because in the event of an emergency, such as airway obstruction or trauma, quick access to wire cutters is crucial to ensure timely removal of the jaw fixation wires. Without immediate access to wire cutters, the client may suffer serious complications. Incorrect choices: A: "We can teach you some relaxation techniques to minimize your pain." - While pain management is important, it is not the priority in this situation where the immediate risk is airway compromise. C: "Use a water pick device to keep your teeth clean." - Oral hygiene is important but not as critical as ensuring access to wire cutters for emergency situations. D: "Consume a high-protein, liquid diet." - Nutrition is important for healing but is not as time-sensitive as having wire cutters readily available in case of an emergency.
Question 4 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 5 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.