ATI RN
Basic Nursing Care of a Neurosurgery Patient Questions
Question 1 of 5
The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol?
Correct Answer: A
Rationale: The correct answer is A: Warfarin. Warfarin is an anticoagulant and increases the risk of bleeding during surgery. Holding warfarin before surgery is crucial to minimize bleeding complications. Vitamin C, Prednisone, and Acetaminophen do not pose the same bleeding risk and can be safely continued before surgery. Each of these medications serves a different purpose and does not interfere significantly with surgical outcomes.
Question 2 of 5
You are treating an adult trauma patient who was thrown from a moving vehicle. Upon assessment, you find the patient is hypotensive, has absent breath sounds on the right, and has visible tracheal deviation. What should you do first?
Correct Answer: A
Rationale: The correct answer is A: Perform a needle decompression. This is the first step because the patient likely has a tension pneumothorax, which is a life-threatening condition causing tracheal deviation, absent breath sounds, and hypotension. Needle decompression helps release the trapped air in the pleural space, alleviating the pressure on the heart and lungs. Administering a fluid bolus (choice B) may worsen the tension pneumothorax by increasing intrathoracic pressure. Intubation (choice C) may be necessary but should not be the first step in managing a tension pneumothorax. Placing the patient on a cardiac monitor (choice D) is important but not the immediate priority in this critical situation.
Question 3 of 5
You are working a respiratory arrest patient and have just successfully placed a combi-tube in your apneic patient. What should you do if the chest fails to rise appropriately and gastric sounds are present?
Correct Answer: C
Rationale: The correct answer is C: Remove the BVM from tube #1 and ventilate through tube #2. If gastric sounds are present along with inadequate chest rise, it indicates that the tube may be in the esophagus rather than the trachea. By removing the BVM from tube #1 and ventilating through tube #2, you can provide ventilation directly to the lungs and avoid insufflating air into the stomach. This step ensures proper oxygenation and ventilation while preventing complications from gastric insufflation. It is essential to act promptly to optimize patient outcomes. Incorrect answers: A: Securing the tube and ventilating through tube #1 would continue to insufflate air into the stomach, worsening the situation. B: Confirming placement with a CO2 detector before ventilating through tube #1 may delay appropriate intervention, risking patient harm. D: Pulling the combi-tube back approximately 2 cm without addressing the issue of gastric sounds and inadequate chest rise would
Question 4 of 5
Your suspected myocardial infarction patient has exhibited ST elevation in Leads II, III, aVF on the electrocardiogram. What area of the heart do you suspect is being damaged?
Correct Answer: B
Rationale: The correct answer is B: Inferior wall. ST elevation in Leads II, III, aVF indicates an inferior wall myocardial infarction. These leads correspond to the inferior part of the heart supplied by the right coronary artery. The ST elevation in these leads suggests acute injury or infarction in this area. The other choices are incorrect because: A: Lateral wall is typically indicated by ST elevation in Leads I, aVL, V5-V6. C: Anterior wall is typically indicated by ST elevation in Leads V1-V4. D: Septal wall is typically indicated by ST elevation in Leads V1-V2.
Question 5 of 5
Which of the following medical conditions or injuries is most likely to cause problems with both the internal and external processes of normal respiration?
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. This condition can cause problems with both internal (heart function affecting oxygenated blood supply) and external (air exchange in lungs) processes of respiration. The heart's inability to effectively pump blood can lead to fluid buildup in the lungs, impairing oxygen exchange. Lung cancer (A) primarily affects the internal processes of respiration. Chronic hypertension (B) mainly impacts blood pressure regulation but not both internal and external respiration. Emphysema (D) primarily affects the external processes of respiration by damaging the lung tissue.