ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
A client's arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The client is experiencing which of the following acid-base imbalances?
Correct Answer: C
Rationale: The correct answer is C: Respiratory acidosis. In this case, the low pH indicates acidosis, and the elevated PaCO2 indicates respiratory involvement. In respiratory acidosis, the lungs cannot eliminate enough CO2, leading to an increase in carbonic acid and a decrease in pH. Metabolic acidosis (choice A) would involve a primary decrease in bicarbonate levels, not seen in this scenario. Metabolic alkalosis (choice B) would involve an increase in bicarbonate levels, which is not indicated by the given information. Respiratory alkalosis (choice D) would have a low PaCO2 and an elevated pH, opposite of what is seen here.
Question 2 of 5
A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?
Correct Answer: D
Rationale: The correct answer is D: Reposition the client. This action should be taken because chest burning could indicate that the chest tube is irritating the pleura. Repositioning the client may help alleviate the pressure on the pleura, reducing discomfort. Increasing wall suction (A) could worsen the irritation. Stripping the chest tube (B) is outdated and can cause damage. Clamping the chest tube (C) can lead to tension pneumothorax.
Question 3 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 4 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 5 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.