ATI RN
Basic Principles of Long-Term Patient Care Developing a Therapeutic Community Questions
Question 1 of 5
The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action?
Correct Answer: B
Rationale: The correct answer is B because obtaining a complete set of vital signs before transport allows for baseline comparison and monitoring for any variations during the transport process. This is crucial in identifying any potential complications or changes in the patient's condition. It ensures continuity of care and early detection of any issues. A: This choice is incorrect as obtaining vital signs before transport is more about monitoring changes rather than completing a head-to-toe assessment. C: This choice is incorrect because obtaining vital signs is not solely to ensure that the nurse checks on the patient postoperatively. D: This choice is incorrect as the primary rationale is not just to follow hospital policy, but rather to monitor vital signs for changes during transport.
Question 2 of 5
After assisting a full-term pregnant patient in the delivery of her newborn, the newborn remains bradycardic with a heart rate of 50 beats per minute and exhibits cyanosis around his mouth, nose, fingers, and toes. He is not responding well and appears lethargic following the five-minute APGAR assessment. What would be the best initial intervention at this point to increase his heart rate?
Correct Answer: A
Rationale: The correct initial intervention is to deliver adequate artificial ventilation after ensuring a definitive airway. This is because the newborn's bradycardia and cyanosis indicate respiratory distress, which can lead to decreased oxygenation and poor perfusion. Ventilating the newborn will help improve oxygenation and increase the heart rate. Administering epinephrine or vasopressors would be premature without addressing the underlying cause of respiratory distress. 'Fast and hard' chest compressions are not indicated for a bradycardic newborn with respiratory distress.
Question 3 of 5
While conducting an EKG on your post-myocardial infarction patient, you note the presence of consistently wide QRS complexes greater than 120 ms in duration. What does this most likely indicate?
Correct Answer: A
Rationale: Step 1: Wide QRS complexes greater than 120 ms indicate abnormal conduction in the ventricles. Step 2: An intraventricular conduction delay or bundle branch block can cause widened QRS complexes. Step 3: In post-myocardial infarction patients, conduction abnormalities like bundle branch blocks are common. Step 4: Choice A is correct as it aligns with the common occurrence of conduction delays post-MI. Step 5: Choices B, C, and D are incorrect as they do not directly relate to widened QRS complexes in this context.
Question 4 of 5
You are on-scene with an apneic adult who collapsed one to two minutes prior to your arrival, according to bystanders. Which of the following endotracheal tube size ranges would be most appropriate for an average adult respiratory arrest patient who shows no signs of airway trauma or obstruction?
Correct Answer: C
Rationale: The correct answer is C: 7.5-8.5 ET tube. This size range is most appropriate for an average adult respiratory arrest patient with no signs of airway trauma or obstruction. Rationale: 1. Size range 7.5-8.5 is standard for adult males and females with average airway anatomy. 2. Choosing too small a tube (option D) can lead to inadequate ventilation. 3. Choosing too large a tube (options A and B) can cause trauma to the airway and increase the risk of complications. 4. Considering the patient has no signs of airway trauma or obstruction, a mid-range size tube (option C) provides a balance between effective ventilation and minimizing potential harm. In summary, option C is the most appropriate choice as it balances the need for effective ventilation while minimizing the risk of complications in an average adult respiratory arrest patient.
Question 5 of 5
You are preparing to perform synchronized electrical cardioversion with a biphasic defibrillator on your unstable adult patient who is experiencing supraventricular tachycardia at 160 beats per minute on the monitor. Which of the following initial energy settings would be recommended if he was exhibiting a narrow complex, regular supraventricular tachycardia, in which his palpable carotid pulse matches the rhythm on the monitor?
Correct Answer: A
Rationale: The correct initial energy setting for synchronized electrical cardioversion in this scenario is option A: Synchronized cardioversion at 50-100 joules. This is because the patient is stable with a narrow complex, regular supraventricular tachycardia, and synchronized cardioversion is indicated for this condition. The recommended starting energy range for synchronized cardioversion in this case is typically 50-100 joules. This energy setting is appropriate for converting supraventricular tachycardia back to sinus rhythm without causing unnecessary harm to the patient. Summary of other choices: - B: Defibrillation at 100 joules: Defibrillation is not indicated for stable supraventricular tachycardia; it is used for ventricular fibrillation or pulseless ventricular tachycardia. - C: Synchronized cardioversion at 360 joules: This energy setting is too high for a stable patient with supraventricular tach