ATI RN
Basic Nursing Care of a Neurosurgery Patient Questions
Question 1 of 5
A pulse oximeter sensor is normally clipped on a person's
Correct Answer: B
Rationale: The correct answer is B: Finger. A pulse oximeter measures oxygen saturation in the blood by clipping onto a person's finger. The finger is chosen because it is easily accessible, has good blood flow, and provides accurate readings. Clipping the sensor on the neck (A) is incorrect as it may obstruct blood flow and provide inaccurate readings. The stomach (C) and lower arm (D) are also not ideal locations as they do not have as strong blood flow as the finger, leading to less accurate results.
Question 2 of 5
The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol?
Correct Answer: A
Rationale: Step 1: Warfarin is an anticoagulant that increases the risk of bleeding during surgery. Step 2: Holding Warfarin helps normalize the patient's clotting ability before surgery. Step 3: This reduces the risk of excessive bleeding during and after the procedure. Step 4: Vitamin C, Prednisone, and Acetaminophen do not pose the same bleeding risk. Summary: Warfarin is the correct choice due to its anticoagulant properties, making it crucial to discontinue before surgery to minimize bleeding complications. Vitamin C, Prednisone, and Acetaminophen do not have the same impact on clotting and are safe to continue.
Question 3 of 5
The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take?
Correct Answer: C
Rationale: The correct answer is C: Measure and record all intake and output. This action is most appropriate for monitoring fluid and electrolyte balance in a postoperative patient as it helps to assess if the patient is receiving adequate fluids and excreting appropriately. By measuring and recording intake and output, the nurse can identify any imbalances and take necessary interventions. Encouraging copious amounts of water (A) without monitoring intake and output can lead to fluid overload or imbalance. Starting an additional IV line (B) may not be necessary if the patient's current IV is functioning properly. Weighing the patient and comparing with preoperative weight (D) is important but may not provide real-time information on fluid and electrolyte balance.
Question 4 of 5
You are treating an adult trauma patient who was thrown from a moving vehicle. Upon assessment, you find the patient is hypotensive, has absent breath sounds on the right, and has visible tracheal deviation. What should you do first?
Correct Answer: A
Rationale: The correct answer is A: Perform a needle decompression. Tracheal deviation indicates tension pneumothorax, a life-threatening condition that requires immediate decompression. Performing a needle decompression will release the trapped air in the pleural space and relieve the pressure on the heart and lungs, stabilizing the patient's condition. Administering a fluid bolus (B) is not the priority as the hypotension is likely due to the tension pneumothorax. Intubating the patient (C) may worsen the condition by increasing the intrathoracic pressure. Placing the patient on a cardiac monitor (D) is important but not as urgent as addressing the tension pneumothorax.
Question 5 of 5
You are working a respiratory arrest patient and have just successfully placed a combi-tube in your apneic patient. What should you do if the chest fails to rise appropriately and gastric sounds are present?
Correct Answer: C
Rationale: The correct answer is C: Remove the BVM from tube #1 and ventilate through tube #2. This is the correct action because the presence of gastric sounds indicates that the tube is likely in the esophagus, not the trachea. By removing the BVM from tube #1 and ventilating through tube #2, you are ventilating the patient's lungs directly, improving oxygenation. Choice A is incorrect because ventilating through tube #1 will not improve the patient's condition if the tube is in the esophagus. Choice B is incorrect because confirming placement with a CO2 detector before ventilating through tube #1 does not address the issue of gastric sounds indicating esophageal placement. Choice D is incorrect because pulling the combi-tube back 2 cm without addressing the issue of esophageal placement will not improve ventilation.