A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

Questions 40

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PN ATI Capstone Adult Medical-Surgical 1 Quiz Questions

Question 1 of 9

A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

Correct Answer: B

Rationale: When using the ABC approach to client care, the nurse should identify that the priority intervention is administering oxygen. In this scenario, the client's oxygen saturation is only 91%, which is below the normal range of 95% and above. Oxygen is essential for adequate tissue perfusion and oxygenation of vital organs. Administering oxygen takes precedence over other interventions to ensure the client's physiological needs are met first. Choice A can be addressed after ensuring adequate oxygenation. Choice C is important for preventing postoperative complications but is not as urgent as addressing oxygen saturation. Choice D is a common postoperative intervention, but in this case, ensuring adequate oxygenation is the priority over IV fluid administration.

Question 2 of 9

A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure?

Correct Answer: A

Rationale: The correct answer is A, Propofol. Propofol is a short-acting anesthetic medication commonly used to induce moderate sedation for procedures like a colonoscopy. This medication provides rapid onset and recovery, making it an ideal choice for such procedures. Choice B, Pancuronium, is a neuromuscular blocking agent used for muscle relaxation during surgery and would not be appropriate for sedation during a colonoscopy. Choice C, Promethazine, is an antihistamine used for nausea and motion sickness, not for anesthesia. Choice D, Pentoxifylline, is a medication used to improve blood flow in patients with circulation problems and is not indicated for anesthesia during a colonoscopy.

Question 3 of 9

A client with M©ni¨re's disease is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan?

Correct Answer: D

Rationale: The correct intervention for a client with M©ni¨re's disease experiencing vertigo is to provide a low sodium diet. Limiting sodium helps to reduce fluid retention, which in turn decreases the manifestations of M©ni¨re's disease. Encouraging bed rest (Choice A) may be necessary during acute episodes but is not a long-term solution. Restricting fluid intake (Choice B) to the morning hours does not specifically address the underlying issue of fluid retention associated with M©ni¨re's disease. Administering aspirin (Choice C) is not recommended for M©ni¨re's disease as it can worsen symptoms.

Question 4 of 9

A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

Correct Answer: A

Rationale: A distended, board-like abdomen is a concerning sign indicating the possibility of a ruptured appendix and peritonitis, which are medical emergencies. Reporting this finding immediately is crucial for prompt intervention. Choice B, an elevated WBC count, could indicate infection but is not as urgent as the risk of a ruptured appendix. Choice C, rebound tenderness over McBurney's point, is a classic sign of appendicitis but does not indicate an immediate threat like a possible rupture. Choice D, a slightly elevated temperature, is a nonspecific finding and not as critical as the risk of peritonitis associated with a distended, board-like abdomen.

Question 5 of 9

A client newly diagnosed with nephrotic syndrome is being taught by a nurse. Which statement indicates that the client understands the teaching?

Correct Answer: A

Rationale: The correct answer is A: "I can expect swelling in my hands and on my face." Nephrotic syndrome leads to increased permeability of the glomeruli, resulting in edema, especially in the face and dependent areas. Choice B is incorrect because nephrotic syndrome leads to protein loss in the urine, not an increase in blood protein levels. Choice C is incorrect as stomach pain and gas are not typical symptoms of nephrotic syndrome. Choice D is unrelated to the teaching about nephrotic syndrome and gum bleeding.

Question 6 of 9

A client has been diagnosed with tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?

Correct Answer: B

Rationale: Tuberculosis is spread through small droplets, measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client with TB under airborne precautions to prevent the transmission of the disease. Choice A, contact precautions, are used for diseases that spread by direct or indirect contact. Choice C, droplet precautions, are for diseases transmitted by large droplets. Choice D, protective environment, is used for clients who have compromised immune systems.

Question 7 of 9

A client with burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?

Correct Answer: D

Rationale: The nurse should encourage the client to attend a support group for individuals with burn injuries. Support groups can provide emotional support, promote acceptance of altered appearance, and help the client cope with the changes. Choice A is incorrect because it may not address the client's emotional needs. Choice B is incorrect as suggesting a timeline for cosmetic surgery may not be appropriate without considering the client's physical and emotional readiness. Choice C is incorrect as reconstructive surgery may not completely restore the client's previous appearance and may set unrealistic expectations.

Question 8 of 9

A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

Correct Answer: A

Rationale: A sodium level of 122 mEq/L indicates hyponatremia, which is characterized by decreased deep tendon reflexes. Hyponatremia leads to neurological symptoms such as altered reflexes. Choices B, C, and D are not typically associated with hyponatremia. Positive Trousseau's sign is related to hypocalcemia, hypoactive bowel sounds can be seen in paralytic ileus or decreased peristalsis, and sticky mucous membranes are not specific findings related to sodium imbalances.

Question 9 of 9

A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?

Correct Answer: C

Rationale: Keeping the client's neck in a midline position is essential when caring for a client with increased intracranial pressure (ICP) as it helps promote optimal blood flow and reduces the risk of further increasing ICP. Placing pillows behind the client's head (Choice A) may not be recommended as it could potentially increase ICP. Putting the client in a Sims' position (Choice B) and maintaining hip flexion at a 90° angle (Choice D) are not directly related to managing increased ICP and are not the priority interventions in this situation.

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