Priority Decision: Upon admission of a patient to the PACU, the nurse's priority assessment is

Correct Answer: C

Rationale: In the context of the ATI Medical Surgical Proctored Exam, the priority assessment upon admission of a patient to the PACU (Post-Anesthesia Care Unit) is respiratory adequacy (Option C). This is the correct answer because assessing the patient's respiratory status is crucial in this setting. Anesthesia can depress respiratory drive, leading to potential complications such as hypoventilation, airway obstruction, or respiratory arrest. Assessing vital signs (Option A) is important but not the immediate priority when the patient is in the PACU. While monitoring vital signs is essential, focusing on respiratory adequacy takes precedence due to the potential risks associated with anesthesia. Assessing the surgical site (Option B) is important for monitoring for bleeding, infection, or other surgical complications; however, it is not the priority upon admission to the PACU. Assessing the level of consciousness (Option D) is also important, but it is secondary to ensuring adequate ventilation and oxygenation in a post-anesthesia patient. Educationally, understanding the priority assessments in the immediate post-operative period is crucial for nurses caring for surgical patients. This knowledge ensures that critical issues are addressed promptly, leading to better patient outcomes and safety.

Correct Answer: C

Rationale: In the context of a patient experiencing emotional and physiologic stress post-major surgery, the correct answer is C) Fluid retention. This stress can lead to the release of stress hormones like cortisol and aldosterone, which can cause the body to retain sodium and water, resulting in fluid retention. This can manifest as edema and contribute to complications like heart failure. Option A) Diuresis is incorrect because stress typically leads to fluid retention, not diuresis, which is the increased production of urine. Option B) Hyperkalemia is incorrect as stress typically does not directly cause high levels of potassium in the blood. Hyperkalemia is more commonly associated with conditions like kidney disease or certain medications. Option D) Impaired blood coagulation is incorrect in this scenario because stress-induced fluid retention does not directly impact blood coagulation. Impaired blood coagulation is more commonly associated with factors like clotting disorders or medications affecting coagulation. Educationally, understanding the physiological responses to stress and surgery is crucial for nurses to provide optimal care to postoperative patients. Recognizing the impact of stress on fluid balance can help nurses anticipate and manage potential complications related to fluid retention.

Correct Answer: D

Rationale: In the context of a hemiplegic patient, the correct initial goal for ambulation is the ability to transfer from bed to chair (Option D). This is because successful bed to chair transfers are crucial for promoting independence and mobility in hemiplegic patients. Mastering this skill enhances the patient's ability to perform activities of daily living and is a fundamental step towards eventual ambulation. Option A, acceptance of altered body image, is not the immediate priority for achieving ambulation. While addressing body image concerns is important for overall psychological well-being, it is not directly related to the physical ability to ambulate. Option B, balance training, is essential for safe ambulation, but before focusing on balance, the patient must first demonstrate the ability to transfer from bed to chair effectively. Without this foundational skill, balance training may not be as effective or safe. Option C, adequate energy level, is important for sustaining ambulation efforts, but it is not the initial step in the care plan. Energy levels can be addressed and improved once the patient has successfully mastered bed to chair transfers and is progressing towards ambulation. In an educational context, understanding the sequential and progressive nature of rehabilitation goals in hemiplegic patients is crucial for developing effective care plans. By prioritizing tasks based on their significance and impact on the patient's functional independence, healthcare professionals can optimize outcomes and promote successful rehabilitation.

Correct Answer: A

Rationale: The correct answer is A) permit drainage of aqueous humor from the anterior chamber. A peripheral iridectomy is a surgical procedure performed to create a small hole in the iris to allow for better drainage of aqueous humor in conditions like narrow-angle glaucoma. This procedure helps to relieve intraocular pressure and prevent further damage to the optic nerve. Option B) promoting the formation of permanent anterior synechiae with the cornea is incorrect because synechiae are adhesions between structures in the eye, which can lead to complications like angle-closure glaucoma, not the intended outcome of the procedure. Option C) promoting the formation of permanent posterior synechiae with the lens is also incorrect. Posterior synechiae are adhesions between the iris and the lens, which can lead to issues like posterior capsular opacification, not the goal of a peripheral iridectomy. Option D) gaining access to the lens for easy removal is not the purpose of a peripheral iridectomy. This procedure is specifically performed to address issues related to intraocular pressure and aqueous humor drainage, not for accessing or removing the lens. Understanding the purpose and implications of a peripheral iridectomy is crucial for nurses and healthcare professionals working with patients with glaucoma or other eye conditions requiring this procedure. It is essential to grasp the rationale behind each option to provide safe and effective care to patients undergoing such surgeries.

Correct Answer: A

Rationale: In this scenario, the most appropriate emergency treatment for Mr. Jones, who has a branch lodged in his eye with bleeding eyelid, is to cover the eye with a protective shield (Option A). This action helps to prevent further injury by providing a barrier that can stabilize the foreign object and protect the eye from additional trauma. Option B, encouraging Mr. Jones to hold his eye closed tightly, is incorrect as it may cause further damage by putting pressure on the foreign object. Option C, applying a pressure dressing to the eye, is also inappropriate as it can exacerbate the situation by increasing pressure on the lodged branch and causing more harm. Option D, removing the foreign body and applying a sterile dressing, is not recommended in this situation as removing the object without proper medical equipment and expertise can lead to more severe damage to the eye. Educationally, this question highlights the importance of understanding first aid principles in emergency situations involving eye injuries. It emphasizes the need to prioritize protecting the eye and seeking professional medical help promptly to prevent complications and ensure the best possible outcome for the patient.