ATI RN
Basic Nursing Care Needs of the Patient PPT Questions
Question 1 of 5
One complication of immobility for the integumentary system is
Correct Answer: D
Rationale: The correct answer is D: Pressure injuries. Immobility reduces blood flow to the skin, leading to pressure injuries like bedsores. Constipation (A) is a complication of immobility for the digestive system. Blood clots (B) are a complication for the circulatory system. Muscle atrophy (C) is a complication for the muscular system due to lack of movement.
Question 2 of 5
During preoperative assessment for a 7:30 AM (0730) surgery, the nurse finds the patient drank a cup of coffee this morning. The nurse reports this information to the anesthesia provider. Which action does the nurse anticipate next?
Correct Answer: A
Rationale: The correct answer is A: A delay in or cancellation of surgery. Consuming coffee before surgery can lead to increased gastric fluid volume and acidity, potentially increasing the risk of aspiration during anesthesia induction. To minimize this risk, surgery may be delayed or canceled to allow time for the stomach to empty. Summary: B: Questions regarding components of the coffee - Irrelevant as the concern is the effect of coffee on gastric fluid. C: Additional questions about why the patient had coffee - Irrelevant, the focus is on the impact of coffee on surgery. D: Instructions to determine what education was provided in the preoperative visit - Irrelevant, the immediate concern is the impact of coffee on surgery.
Question 3 of 5
Your adult patient called for help after he began to vomit bright red blood. On arrival, the patient is found to be tachycardic and bleeding freely from his mouth. His respirations are shallow, and his skin is cool with a blood pressure of 68 systolic. His only history involves liver disease from chronic alcoholism. He denies drinking recently. What should be the goal of your pre-hospital intervention with this patient after ensuring his airway and applying oxygen therapy?
Correct Answer: A
Rationale: The correct answer is A: Fluid resuscitation to maintain a systolic blood pressure of 80-90 systolic. In this scenario, the patient is presenting signs of hypovolemic shock due to significant blood loss. The goal of fluid resuscitation is to restore intravascular volume and improve perfusion to vital organs. A systolic blood pressure of 80-90 is a reasonable target to ensure adequate perfusion without causing fluid overload. Choice B is too high of a target for this patient in shock. Choice C is not the immediate priority as controlling the hemorrhage comes first. Choice D is not the primary goal in this critical situation where maintaining blood pressure and perfusion are the priorities.
Question 4 of 5
A patient is experiencing a possible neurological emergency from a blunt force closed head injury. He is found to have abnormal pupillary reactions to light and has lost the ability to move his eyes from side to side to follow your finger movements. He is also unable to identify the number of fingers you are holding up. He reports he is able to see the fingers but is not able to focus enough to identify how many fingers are present. Which of the following cranial nerves should you suspect may be involved in his injury?
Correct Answer: D
Rationale: Step-by-step rationale: 1. Cranial nerve II (Optic nerve) is responsible for vision. Loss of ability to identify the number of fingers indicates optic nerve involvement. 2. Cranial nerve III (Oculomotor nerve) controls eye movements, including pupillary reactions. Abnormal pupillary reactions suggest its involvement. 3. Cranial nerve IV (Trochlear nerve) controls downward and inward eye movements. Inability to move eyes side to side implicates trochlear nerve. Summary: A: Cranial nerves I, V, and VI - Not relevant for the symptoms described. B: Cranial nerves V and VII - Cranial nerve VII (Facial nerve) is not involved in eye movements or vision. C: Cranial nerves IX and X - Not related to vision or eye movements. D: Cranial nerves II, III, and IV - Correct as all three nerves are implicated in the patient's symptoms.
Question 5 of 5
You are the first ambulance to arrive on the scene of a single-car accident. As you approach the scene, you see four patients, two have been ejected from their vehicle, and two are still in the vehicle. What should be your next course of action?
Correct Answer: B
Rationale: The correct answer is B: Request additional resources, such as fire rescue, and additional ambulances to respond to the scene. This is the best course of action because, in a single-car accident with multiple patients, the scene is likely to be complex and require additional resources to manage effectively. Requesting fire rescue can help with extrication of patients still in the vehicle, while additional ambulances ensure there are enough resources to transport all patients promptly. This approach prioritizes patient care and safety by ensuring all necessary resources are available to manage the situation efficiently. Choice A: Calling medical control is important but should not be the first step in this scenario where immediate action is needed. Choice C: Beginning immediate triage and treatment of the two ejected patients might overlook the need for additional resources and proper scene management. Choice D: Notifying the local trauma center is important but should come after requesting additional resources to manage the scene effectively.