ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 5
A patient is prescribed an opioid analgesic for postoperative pain management. Which nursing intervention is essential for preventing respiratory depression in the patient?
Correct Answer: B
Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.
Question 2 of 5
A patient is prescribed an opioid analgesic for the management of acute pain. Which adverse effect should the nurse monitor closely in the patient?
Correct Answer: C
Rationale: Opioid analgesics are known to suppress the respiratory centers in the brain, leading to respiratory depression as a side effect. This adverse effect is particularly dangerous and potentially life-threatening, especially in patients who are opioid-naive or when high doses are administered. Therefore, it is crucial for the nurse to closely monitor the patient's respiratory rate, depth, and effort while on opioid analgesic therapy to detect early signs of respiratory depression and intervene promptly to prevent complications. Hypertension, hypoglycemia, and hyperkalemia are not commonly associated with opioid analgesics.
Question 3 of 5
While preparing the operating room (OR) for a surgical procedure, the nurse notices a malfunctioning anesthesia machine. What is the nurse's priority action?
Correct Answer: C
Rationale: The nurse's priority action when noticing a malfunctioning anesthesia machine in the operating room should be to inform the anesthesia provider immediately. Anesthesia providers are responsible for administering anesthesia safely during surgical procedures, and they need to be made aware of any equipment issues promptly to ensure patient safety. Continuing with the surgical procedure using a malfunctioning anesthesia machine can pose serious risks to the patient's well-being. Using an alternative anesthesia machine may be an option, but informing the anesthesia provider first ensures that the appropriate action is taken to address the issue effectively. Documenting the malfunction in the equipment log is important for record-keeping purposes, but it should not take precedence over informing the anesthesia provider and taking immediate action to address the problem.
Question 4 of 5
After the surgical procedure, the nurse assists with applying the surgical dressing. What is the nurse's priority action?
Correct Answer: B
Rationale: The nurse's priority action after applying the surgical dressing is to assess the surgical incision for signs of complications. This includes checking for any signs of infection, excessive bleeding, or other complications related to the surgical site. Early detection of such complications is crucial for ensuring proper healing and preventing serious complications. Once the assessment is done and any issues are addressed, the nurse can proceed with documenting the dressing change, providing instructions to the patient about wound care, and ensuring that the dressing is securely and correctly applied.
Question 5 of 5
During a shift handover, the nurse receives information about a patient's condition from the outgoing nurse. What action by the nurse demonstrates effective communication during the handover process?
Correct Answer: C
Rationale: Option C, summarizing key points and asking clarifying questions as needed, demonstrates effective communication during the handover process. This action ensures that the nurse fully understands the information being provided and helps to prevent misunderstandings or missing critical details. By summarizing key points, the nurse confirms their understanding and can ask for clarification on any areas that are unclear. Effective communication during handovers is essential for maintaining patient safety and continuity of care.