ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 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 3 of 5
A 72-year-old female client is lifted to the surgery table in preparation for a total knee replacement. The client is in stage III of inhalation anesthesia. An appropriate nursing action for this client is:
Correct Answer: B
Rationale: Preventing injury by restraining the client, if necessary, is a nursing action of stage II, which extends from loss of consciousness to relaxation. Stage III extends from the loss of lid reflex to cessation of voluntary respirations. Operative procedures are performed during stage III of inhalation anesthesia. Promoting restoration of ventilation and vasomotor tone is a nursing action for stage IV in which an overdose has occurred. Respiratory arrest and vasomotor collapse result from medullary paralysis. Reduction of external stimuli is a nursing action for stage I, which extends from induction to loss of consciousness.
Question 4 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 5 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.