ATI LPN
Perioperative Nursing Care Questions Questions
Question 1 of 5
The nurse is providing care for a patient on postoperative day 1 following a craniotomy. The patient's blood pressure is 160/90 mm Hg, and pulse is 50 beats per minute. What should the nurse suspect?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 of 5
A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
A postoperative client has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations 24 breaths/min. What action by the nurse is most appropriate?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?
Correct Answer: A
Rationale: The Mantoux test, used to screen for tuberculosis exposure, requires precise administration to ensure accurate results. It involves injecting purified protein derivative (PPD) intradermally into the inner forearm, creating a small wheal just under the skin surface. This method targets the dermal layer where immune cells can react to the antigen, producing a measurable induration if the child has been exposed to TB. Intramuscular injections into the vastus lateralis or subcutaneous injections into the umbilical area or deltoid are inappropriate because they deliver the substance too deeply or into fatty tissue, preventing the localized skin reaction needed for interpretation. The intradermal technique, typically at a 5-15 degree angle with a fine needle, ensures the PPD remains in the dermis, maximizing sensitivity and specificity of the test, which is critical for early detection in a pediatric population.
Question 5 of 5
The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patients symptoms from those of a cardiac etiology?
Correct Answer: B
Rationale: In early ARDS, distinguishing respiratory failure from cardiac causes like congestive heart failure (CHF) is crucial, and brain natriuretic peptide (BNP) levels are the most likely test ordered. Elevated BNP, secreted by the heart under strain, indicates cardiac etiology (e.g., pulmonary edema from CHF), whereas normal or low BNP supports ARDS, a non-cardiogenic lung injury with alveolar flooding. Carboxyhemoglobin measures carbon monoxide poisoning, relevant to inhalation injury but not routine for ARDS differentiation. CRP reflects inflammation, common in both ARDS and infection, but lacks specificity for cardiac versus pulmonary origin. A complete blood count provides general health data (e.g., infection) but doesn't pinpoint etiology. BNP, often paired with echocardiography, guides the nurse and team to tailor treatment ventilation for ARDS versus diuretics for CHF ensuring accurate early management of this critical condition.