ATI RN
Free Medical Surgical Certification Practice Questions Questions
Question 1 of 5
While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Stay with the client and ask someone else to contact the provider immediately. Rationale: 1. Pulsation of the tracheostomy tube with heartbeat indicates the tube is very close to a major blood vessel. 2. Immediate provider notification is crucial to prevent potential complications. 3. Removing the tube without professional guidance can lead to severe bleeding and airway compromise. 4. Contacting the provider promptly ensures timely intervention and appropriate next steps. Summary: A: Notifying the operating room is premature and unnecessary at this point. B: Pulsation may not always be normal and warrants immediate action. C: Removing the tube without professional guidance can be harmful to the client.
Question 2 of 5
What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?
Correct Answer: A
Rationale: The correct answer is A - Apply water-soluble ointment to nares and lips. This is an appropriate comfort measure that can be safely delegated to UAP as it helps prevent dryness and irritation caused by the oxygen flow. UAP can apply ointment without adjusting the oxygen flow rate (B), which should be done by licensed staff. Removing the tubing (C) can disrupt oxygen delivery. Turning the client (D) is important for preventing pressure ulcers but is not directly related to oxygen therapy comfort.
Question 3 of 5
A client is wearing a Venturi mask to receive oxygen, and the dinner tray has arrived. What action by the nurse is best?
Correct Answer: B
Rationale: The correct answer is B: Determine if the client can switch to a nasal cannula during the meal. This is the best action because the client can maintain oxygen therapy while eating without the obstruction of the Venturi mask. Switching to a nasal cannula allows for continued oxygen delivery during meals. A: Assessing the client's oxygen saturation and turning off the oxygen if normal is incorrect because the client still needs oxygen support during meals. C: Having the client lift the mask off the face when taking bites of food is incorrect as it disrupts continuous oxygen therapy. D: Turning off the oxygen while the client eats the meal and then restarting it is incorrect as it interrupts oxygen therapy, which should be continuous for clients requiring oxygen support.
Question 4 of 5
During an acute asthma attack, a healthcare provider assesses a client. Which assessment finding indicates that the client's condition is worsening?
Correct Answer: C
Rationale: The correct answer is C: Decreased breath sounds. This finding indicates worsening asthma as it signifies decreased airflow to the lungs, which can lead to inadequate oxygenation. Loud wheezing (A) is common in asthma but does not necessarily indicate worsening. Increased respiratory rate (B) is a compensatory mechanism to improve oxygenation. Productive cough (D) may indicate clearing of mucus and is not necessarily associated with worsening asthma.
Question 5 of 5
A client is prescribed prednisone for asthma management. Which statement by the client indicates a need for further teaching?
Correct Answer: D
Rationale: The correct answer is D because stopping prednisone abruptly can lead to adrenal insufficiency due to the suppression of the body's natural cortisol production. The client should never stop taking prednisone suddenly without consulting the healthcare provider. Choice A is correct because prednisone is often used as a daily preventive medication for asthma. Choice B is correct as prednisone can lower the immune system, making the client more susceptible to infections. Choice C is incorrect because prednisone is usually taken with food to minimize stomach upset.