ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
Correct Answer: B
Rationale: The correct answer is B: No fluctuations in the water seal chamber. This finding indicates that the lung has re-expanded because it means there is no air leaking from the lung into the pleural space, causing fluctuations in the water seal chamber. Option A, oxygen saturation of 95%, is not directly related to lung re-expansion. Option C, no reports of pleuritic chest pain, is a subjective symptom and does not provide a direct indication of lung re-expansion. Option D, occasional bubbling in the water-seal chamber, indicates air is escaping from the lung into the pleural space, suggesting incomplete lung re-expansion.
Question 2 of 5
During an asthma attack, a healthcare provider is assessing a client for hypoxemia. Which of the following manifestations should the provider expect?
Correct Answer: C
Rationale: The correct answer is C: Agitation. During an asthma attack, hypoxemia can lead to increased respiratory effort and decreased oxygen delivery to tissues, causing agitation. Nausea (A) is not a typical manifestation of hypoxemia in asthma. Dysphagia (B) refers to difficulty swallowing and is not directly related to hypoxemia. Hypotension (D) is unlikely in asthma as it is more commonly associated with shock or severe systemic conditions.
Question 3 of 5
Prior to performing percussion, vibration, and postural drainage on an adolescent client with pneumonia, which of the following nursing actions should the nurse complete first?
Correct Answer: A
Rationale: The correct answer is A: Auscultate lung fields. Before performing percussion, vibration, and postural drainage on a client with pneumonia, it is essential to assess the current condition of the lungs through auscultation. This step provides valuable information about the areas of congestion, lung sounds, and overall respiratory status. By auscultating first, the nurse can determine the appropriate areas to target and assess the effectiveness of the interventions. Assessing pulse and respirations (B) is important but does not directly guide the specific interventions needed for pneumonia. Assessing the characteristics of the sputum (C) is relevant but not as crucial as directly assessing the lung fields. Instructing the client to exhale with pursed lips (D) is not a priority before assessing the lung fields.
Question 4 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 5 of 5
A client has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Continuous bubbling in the water-seal chamber indicates air leaks, which can lead to pneumothorax. 2. Occasional bubbling in the water-seal chamber is normal as air exits the pleural space. 3. Constant bubbling in the suction-control chamber indicates high suction pressure, not a complication. 4. Fluctuations in the fluid level in the water-seal chamber are expected during normal respiration.