ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to:
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 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 3 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 4 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 5 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.