ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 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 2 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 3 of 5
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
Correct Answer: B
Rationale: The correct answer is B: Stridor. Stridor is a high-pitched, inspiratory sound that indicates upper airway obstruction and impending respiratory distress, which is a life-threatening complication of anaphylaxis. The nurse should intervene first by ensuring a patent airway to prevent respiratory compromise. Urticaria (A) is a common symptom of an allergic reaction but does not pose an immediate threat to airway patency. Vomiting (C) can be a sign of gastrointestinal distress but does not require immediate intervention for airway protection. Hypotension (D) is a serious manifestation of anaphylaxis but addressing airway obstruction takes precedence to prevent respiratory failure.
Question 4 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 5 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.