ATI RN
Basic Principles of Long-Term Patient Care Developing a Therapeutic Community Questions
Question 1 of 5
When using a pulse oximetry device
Correct Answer: D
Rationale: The correct answer is D: Supine position. When using a pulse oximetry device, the supine position can lead to inaccurate readings due to reduced blood flow to the extremities. This position can affect the accuracy of oxygen saturation measurements. It is important to keep the patient in an upright or semi-upright position for accurate readings. Choices A, B, and C are incorrect because excessive fluids, loose tape, or avoiding certain actions are not directly related to the accuracy of pulse oximetry readings.
Question 2 of 5
The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to achieve?
Correct Answer: B
Rationale: The correct answer is B: Prevent atelectasis. Diaphragmatic breathing helps improve lung expansion, prevent atelectasis (collapsed lung), and promote oxygenation. By utilizing diaphragmatic breathing, the nurse aims to prevent respiratory complications postoperatively. Managing pain (A) can be addressed through other interventions. While improving oxygenation may indirectly contribute to reducing healing time (C), the main goal is to prevent respiratory complications. Decreasing thrombus formation (D) is not directly related to diaphragmatic breathing.
Question 3 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 4 of 5
Pericardial tamponade and hemorrhagic shock present very similarly in the pre-hospital environment. What is the best way, of those listed, to distinguish between the two diagnoses?
Correct Answer: A
Rationale: The correct answer is A because pericardial tamponade can lead to jugular vein distension due to the increased pressure in the pericardium, which can impede blood flow back to the heart. Hemorrhagic shock, on the other hand, does not typically cause jugular vein distension. This difference in jugular vein distension is a key clinical finding to differentiate between the two conditions. Choice B is incorrect because cyanosis to the face, neck, and upper chest can be present in both pericardial tamponade and hemorrhagic shock, making it less specific for distinguishing between the two. Choice C is incorrect because pericardial tamponade can also lead to hypotension due to decreased cardiac output, while hemorrhagic shock can sometimes lead to compensatory hypertension in its early stages. Choice D is incorrect because the type of tachycardia (narrow vs. wide complex) is not a reliable or consistent finding to
Question 5 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.