ATI LPN
Perioperative Nursing Care Test Questions Questions
Question 1 of 5
An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 of 5
A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurses assessment findings would best corroborate this diagnosis?
Correct Answer: D
Rationale: Pleurisy, inflammation of the pleural membranes, is characterized by sharp pain that worsens with respiratory movements like coughing or deep breathing due to friction between the inflamed parietal and visceral pleura. This pain is typically unilateral and may radiate, but its key feature is its exacerbation with chest motion, making it a hallmark finding in this diagnosis. Painless hemoptysis suggests a different pathology, such as a pulmonary embolism or malignancy, not pleurisy. Normal ABGs with increased work of breathing could indicate early respiratory distress but lacks specificity for pleurisy. Low oxygen saturation without dyspnea might suggest chronic hypoxia or a shunt, not directly supporting pleurisy, which usually causes pain-driven shortness of breath. The nurse's finding of intensified pain during coughing or deep breathing aligns with the pathophysiology of pleural irritation post-trauma, strongly corroborating the suspected diagnosis.
Question 4 of 5
The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis?
Correct Answer: A
Rationale: Atelectasis, the collapse of alveoli, is prevented primarily by promoting lung expansion and airway clearance, making incentive spirometry a first-line measure. This device encourages deep breathing, increasing lung volume and reopening collapsed alveoli, especially in at-risk patients (e.g., postoperative, immobile). It empowers patients to actively improve ventilation, reducing mucus plugging and enhancing gas exchange. IPPB and PEEP, while effective, are advanced interventions requiring equipment and are used when first-line methods fail IPPB delivers pressure to inflate lungs, and PEEP maintains airway pressure in ventilated patients. Bronchoscopy removes obstructions but is invasive, reserved for severe cases. Incentive spirometry's simplicity, accessibility, and efficacy in stimulating natural breathing mechanics make it the nurse's go-to strategy, supported by evidence for preventing postoperative atelectasis and improving respiratory outcomes.
Question 5 of 5
A patient with thoracic trauma is admitted to the ICU. The nurse notes the patients chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated?
Correct Answer: B
Rationale: Subcutaneous emphysema air trapped in subcutaneous tissues, causing swelling and crepitus arises from thoracic trauma (e.g., pneumothorax, bronchial rupture). When severe, it can compress the trachea, threatening airway patency, necessitating a tracheostomy to bypass upper airway obstruction and ensure ventilation. A chest tube treats the underlying pneumothorax, relieving pleural air but not subcutaneous spread impacting the airway directly. Endotracheal intubation may fail if tracheal compression prevents tube passage, making it less effective in this scenario. A feeding tube is irrelevant to airway management. The nurse's anticipation of tracheostomy reflects its role in securing a patent airway when subcutaneous air from trauma escalates, a critical intervention supported by trauma care protocols for maintaining oxygenation.