ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
Alex Rowe develops hives after having eaten strawberries. He states he has strawberries before, and has never had a problem with them before. This is an example of:
Correct Answer: C
Rationale: Idiosyncratic response means it occurs because of an unknown reason. This response to something the body has been exposed to before is not unknown. Autoimmune disorders are ones in which the body attacks self-cells. This example is an outside antigen. Type I hypersensitivities are those that occur when the body, previously sensitized to a substance, is then exposed a second time and reacts. Immunossuppression occurs when the immune system is not working. Mr. Rowe's immune system responded to the antigen, so it is not suppressed.
Question 2 of 5
A 27-year-old client who is three hours postoperative complains of right leg pain after knee reduction surgery. The first action by the nurse should be to:
Correct Answer: C
Rationale: Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but it should not be assessed before checking the affected extremity. The extremity can be elevated if ordered by the physician. Assessment of the postoperative area is important to determine the presence of bleeding, swelling, or decreased circulation. Reinforcement of teaching on the use of the patient-controlled anesthesia (PCA) pump is important, but it is not the first action.
Question 3 of 5
A client returns to the Cardiovascular Intensive Care Unit following a coronary artery bypass graft (CABG). In planning the client's care, the most important electrolyte to monitor is:
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
A postoperative priority nursing diagnosis for a client having a vertical partial laryngectomy would be:
Correct Answer: B
Rationale: The laryngectomy client should be able to gradually increase activities without difficulty. The laryngectomy client may have copious amounts of secretions, which will require suctioning for the first 24-48 hours. Because the mucous collects in the cannula, it will require cleaning after the first 24 hours. Even though the client does have a potential for infection, this is not more important than the ineffective airway clearance. An altered mucous membrane problem is not more important than ineffective airway clearance. The client's mouth may become dry, but can be taken care of with good oral care.
Question 5 of 5
A 29-year-old client is admitted for a hysterectomy and is expressing concern regarding the procedure. Shortly into the preoperative teaching, the client complains of a tightness in the chest, feelings of suffocation, light-headedness, and tingling in the hands. The client's respirations are rapid and deep. The nursing assessment reveals that this client is:
Correct Answer: D
Rationale: Classic symptoms of a heart attack include a heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may also be present. However, the client does not exhibit these symptoms. Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. Symptoms of complete airway obstruction include not being able to speak, lack of airflow between the nose and mouth, and absent breath sounds. A tightness in the chest, feelings of suffocation, light-headedness, tingling in the hands, and rapid deep respirations are signs and symptoms of hyperventilation, which is almost always a manifestation of anxiety.