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: This is done to compare and monitor for vital sign variation during transport. 1. Monitoring vital signs during transport is crucial to detect any changes or complications post-surgery. 2. Comparing pre-transport and post-transport vital signs helps in assessing the patient's stability. 3. Any significant variations in vital signs can indicate potential issues that need immediate attention. 4. This practice ensures continuity of care and promotes patient safety during transitions. Incorrect Choices: A: Completing a head-to-toe assessment is not the primary purpose of obtaining vital signs before transport. C: The medical-surgical nurse obtaining vital signs does not necessarily imply checking on the postoperative patient. D: Following hospital policy and procedure is important but does not specifically address the rationale for checking vital signs 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 answer is A: Deliver adequate artificial ventilation after ensuring a definitive airway. In this scenario, the newborn is bradycardic, cyanotic, and lethargic, indicating possible respiratory distress. The initial intervention should focus on improving oxygenation and ventilation. Providing adequate artificial ventilation after ensuring a definitive airway will help increase oxygen delivery to the newborn's tissues, which can improve the heart rate and overall condition. Epinephrine and vasopressors are not the first-line interventions for bradycardia in a neonate. Fast and hard chest compressions are not recommended as the first step in managing bradycardia in a newborn.
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: The correct answer is A: An intraventricular conduction delay or right/left bundle branch block. Wide QRS complexes (>120 ms) indicate a delay in ventricular depolarization, typically due to conduction abnormalities like bundle branch blocks. In the context of a post-myocardial infarction patient, this finding is common and suggests a conduction issue rather than an acute infarction (choice C). Complete heart block (choice B) would show dissociation between atria and ventricles, not wider QRS complexes. Choice D is incorrect as wide QRS complexes in a post-MI patient require further evaluation and potential intervention.
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. For an adult with no signs of airway trauma or obstruction who is in respiratory arrest, this size range is appropriate. Here's the rationale: 1. Adult size: The range is suitable for an average adult. 2. Apneic adult: The patient is not breathing, requiring intubation for airway management. 3. Timeframe: With a recent collapse, the airway is likely still patent, so a smaller tube is sufficient. 4. No trauma or obstruction: There are no indications for a larger tube. Other choices are incorrect: A: 6.5-8.5 ET tube - This is too broad, and a specific size range is more appropriate. B: 9.0-10.0 ET tube - Larger sizes are not necessary if there are no airway issues. D: 4.5-6.5 ET tube - This size is too small
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 a patient with stable supraventricular tachycardia is A: Synchronized cardioversion at 50-100 joules. This is because the patient is hemodynamically stable, with a narrow complex, regular rhythm, and a palpable carotid pulse matching the monitor. The recommended energy range for synchronized cardioversion in such cases is typically between 50-100 joules. This energy level is sufficient to terminate the tachyarrhythmia without causing unnecessary harm to the patient. Choices B, C, and D are incorrect because defibrillation energy settings (100-360 joules) are too high for a stable supraventricular tachycardia patient. Using such high energy levels could lead to unnecessary myocardial damage and potentially worsen the patient's condition. Therefore, the correct choice is A, as it aligns with the principles of providing effective treatment while minimizing the risk of