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

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PN ATI Capstone Adult Medical-Surgical 1 Quiz Questions

Question 1 of 5

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 5

A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?

Correct Answer: C

Rationale: A low sodium diet is recommended for a client who has hypertension. Therefore, the nurse should recommend 3 oz of chicken breast as the best choice for the client's diet because it contains 30 - 90 mg of sodium. Choice A, 1 packet of reconstituted dry onion soup, and Choice B, 3 oz of lean cured ham, are high in sodium content, which is not suitable for a client with hypertension. Choice D, 1/2 cup of canned baked beans, is also high in sodium, making it a less suitable choice compared to 3 oz of chicken breast.

Question 3 of 5

A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?

Correct Answer: D

Rationale: Clients who have seizures are at risk for injury and aspiration. Therefore, the nurse should instruct the family to position the client on their side during a seizure to maintain a clear airway. Placing a padded tongue depressor near the bedside (Choice A) is not recommended, as it can lead to oral injury during a seizure. Placing a pillow under the client's head (Choice B) can obstruct the airway and increase the risk of aspiration. Administering diazepam orally (Choice C) is not typically done by family members during a seizure; this is usually prescribed by healthcare providers for specific situations.

Question 4 of 5

A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?

Correct Answer: B

Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding indicates meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, choice C refers to coordination issues, and choice D describes neck pain and stiffness, which are not specific to Kernig's sign.

Question 5 of 5

A healthcare provider is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the healthcare provider plan to administer?

Correct Answer: C

Rationale: The client presents with bradycardia, diaphoresis, and chest pain, indicating reduced cardiac output. Atropine is the appropriate choice as it increases heart rate by blocking the parasympathetic nervous system. Lidocaine is used for ventricular arrhythmias, Adenosine for supraventricular tachycardia, and Verapamil for controlling heart rate in atrial fibrillation or atrial flutter. These medications are not suitable for the client's current presentation.

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