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