ATI RN
Basic Nursing Care of a Neurosurgery Patient Questions
Question 1 of 5
The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take?
Correct Answer: C
Rationale: The correct answer is C: Measure and record all intake and output. This action is most appropriate as it helps in assessing the patient's fluid status accurately. By tracking intake and output, the nurse can identify any imbalances and intervene promptly. Encouraging copious amounts of water (A) without monitoring intake and output can lead to fluid overload. Starting an additional IV line (B) may not be necessary if the current IV line is sufficient. Weighing the patient and comparing with preoperative weight (D) is important but may not provide real-time information on fluid and electrolyte balance. Monitoring intake and output is a comprehensive method to assess and manage fluid and electrolyte imbalances effectively.
Question 2 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 3 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 4 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.
Question 5 of 5
You are on-scene with a patient in cardiac arrest. You turn the monitor/defibrillator on and attach the pads to the patient. When it begins to analyze the patient's cardiac rhythm, it signals 'low battery' and then shuts off. You have no other batteries available, and an electrical plug is not available. The patient subsequently dies despite adequate CPR and advanced airway and ventilation during transport. Which of the following could result?
Correct Answer: B
Rationale: The correct answer is B: Negligence charges could be brought against the paramedic in charge of the unit. Rationale: 1. Negligence is the failure to exercise the standard of care that a reasonably prudent person would have in a similar situation. 2. In this scenario, the paramedic in charge failed to ensure the equipment was adequately charged or had backup batteries, leading to the device shutting off during a critical moment. 3. This failure to provide proper equipment falls below the standard of care expected in the field of emergency medical services. 4. As a result, the patient's death could be attributed to the paramedic's negligence in ensuring equipment readiness. Summary: A: Manslaughter charges require a higher level of intent and causation, not applicable here. C: Battery charges refer to physical harm, not applicable in this context. D: Defamation charges involve false statements damaging a person's reputation, not relevant to the situation described.