The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is:

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ATI Medical Surgical Proctored Exam Questions

Question 1 of 5

The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is:

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

Total parenteral nutrition(TPN), is one of the home therapies being used for Chelsea Mann, 35, with acute ulcerative colitis causing massive diarrhea. She and her family will need instruction about:

Correct Answer: A

Rationale: Prevention of infection, and potential septicemia, is of prime importance for someone with a central catheter. Mixing TPN is a very specialized procedure, and should be done under laminar airflow by a pharmacist. IV pumps are machines that do malfunction, but the safest thing to do would be to get the manufacturer to do the repair. Having neighbors be a support to Chelsea and her family may not be possible. More information would be necessary prior to choosing this as an option for a nursing diagnosis.

Question 3 of 5

Following a gastric resection, a 70-year-old male client is admitted to the Post-Anesthesia Care Unit (PACU). The client was extubated prior to leaving the OR suite. Upon arrival at the PACU, the nurse should first:

Correct Answer: A

Rationale: Adequate air exchange and tissue oxygenation depends upon competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but is secondary to airway management. Re-orienting a client to time, place, and person and knowing that their surgery is over is important, but is secondary to airway management and taking vital signs. Airway management takes precedence over the physician's orders, unless the orders specifically relate to airway management.

Question 4 of 5

A client had a hemicolectomy performed two days ago. Today, the nurse assessed the incision and discovered a small part of the abdominal viscera protruding through the incision. This complication of wound healing is known as:

Correct Answer: D

Rationale: Excoriation is an abrasion of the epidermis, or of any organ coating of the body, caused by trauma, chemicals, burns, or other causes. Dehiscence is a partial to complete separation of the wound edges with no abdominal tissue protrusion. Decortication is removal of the surface layer of an organ or structure, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. Evisceration occurs when the incision separates and the contents of the cavity spill out.

Question 5 of 5

A 72-year-old male client had the Foley catheter removed today, which was inserted during the transurethral resection of the prostate (TURP). The client is concerned about the urinary incontinence he has experienced since removal of the Foley catheter. The nurse should explain to the client that:

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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