ATI RN
Free Medical Surgical Certification Practice Questions Questions
Question 1 of 5
A nursing student is providing tracheostomy care. What action by the student requires intervention by the instructor?
Correct Answer: C
Rationale: The correct answer is C: Tying a square knot at the back of the neck. The reason this action requires intervention is that a square knot is not recommended for securing tracheostomy ties as it can be difficult to untie in an emergency. Instead, a quick-release knot or Velcro closure is typically used for easy removal. A: Holding the device securely when changing ties is important for maintaining the integrity of the tracheostomy. B: Suctioning the client first if secretions are present is a standard practice to ensure clear airways. D: Using half-strength peroxide for cleansing is appropriate for tracheostomy care to prevent infection. In summary, the incorrect choice is C because tying a square knot can pose risks in an emergency situation, while the other choices are appropriate actions in tracheostomy care.
Question 2 of 5
While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?
Correct Answer: B
Rationale: The correct answer is B because intact skin behind the ears indicates proper oxygen delivery, ensuring the client's respiratory needs are being met. This assessment finding shows that the oxygen therapy is effective in improving oxygenation. A: This choice is incorrect as the client's meal intake does not directly reflect the effectiveness of oxygen therapy. C: Although important, the client's understanding of the need for oxygen does not directly indicate the success of the oxygen therapy. D: Unchanged weight is not a direct indicator of the effectiveness of oxygen therapy in this situation.
Question 3 of 5
While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Stay with the client and ask someone else to contact the provider immediately. Rationale: 1. Pulsation of the tracheostomy tube with heartbeat indicates the tube is very close to a major blood vessel. 2. Immediate provider notification is crucial to prevent potential complications. 3. Removing the tube without professional guidance can lead to severe bleeding and airway compromise. 4. Contacting the provider promptly ensures timely intervention and appropriate next steps. Summary: A: Notifying the operating room is premature and unnecessary at this point. B: Pulsation may not always be normal and warrants immediate action. C: Removing the tube without professional guidance can be harmful to the client.
Question 4 of 5
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
Correct Answer: B
Rationale: The correct answer is B because joining a book club indicates the client is engaging in social activities and pursuing interests, which can boost self-esteem. Choice A focuses on physical care, not self-esteem. Choice C involves family support, not necessarily self-esteem. Choice D only addresses physical health, not emotional well-being. Overall, engaging in social activities promotes self-worth and a sense of belonging, aligning with the goal of improving self-esteem.
Question 5 of 5
What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
Correct Answer: A
Rationale: The correct answer is A - Apply water-soluble ointment to nares and lips. This is an appropriate comfort measure that can be safely delegated to UAP as it helps prevent dryness and irritation caused by the oxygen flow. UAP can apply ointment without adjusting the oxygen flow rate (B), which should be done by licensed staff. Removing the tubing (C) can disrupt oxygen delivery. Turning the client (D) is important for preventing pressure ulcers but is not directly related to oxygen therapy comfort.