ATI RN
Medical Surgical Nursing Practice Questions Questions
Question 1 of 5
You are taking histories from several clients who report vertigo. Which client report concerns you the most?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Vertigo with hearing loss. This response should concern you the most because vertigo accompanied by hearing loss could indicate an underlying issue with the inner ear, such as Ménière's disease or acoustic neuroma. These conditions can have serious implications for the client's health and require thorough assessment and management. Option B) Episodic vertigo is less concerning than vertigo with hearing loss since it could be related to benign paroxysmal positional vertigo (BPPV) or vestibular migraines, which are generally less severe and easier to manage. Option C) Vertigo without hearing loss may be less alarming as it could be related to conditions like vestibular neuritis or labyrinthitis, which typically do not involve hearing loss and have better prognoses compared to inner ear pathologies. Option D) 'Merry-go-round' vertigo is a term commonly used to describe the sensation of spinning but does not provide specific clinical information that would raise immediate concerns. Educationally, understanding the significance of associated symptoms with vertigo can help nurses prioritize assessments and interventions, leading to improved patient outcomes. Recognizing the red flag of vertigo with hearing loss prompts further investigation and appropriate referrals for a timely and accurate diagnosis.
Question 2 of 5
The third stage of labor is when:
Correct Answer: D
Rationale: In the context of medical surgical nursing, understanding the stages of labor is crucial for providing safe and effective care to mothers and newborns. The third stage of labor is defined by the delivery of the placenta. This stage starts immediately after the birth of the baby and ends with the expulsion of the placenta and its attached membranes. Option A, contractions reaching their peak, describes the first stage of labor, particularly the transition phase. Option B, the head becoming visible, is part of the second stage of labor when the baby is born. Option C, the water breaking, typically occurs in the early stages of labor, specifically during the rupture of membranes. By knowing the specific characteristics of each stage of labor, nurses can accurately assess progress, anticipate complications, and provide appropriate interventions. Understanding the sequence of events in labor also helps nurses educate and support laboring mothers effectively. Therefore, recognizing that the correct answer is D, the delivery of the placenta, is essential for providing high-quality care during the third stage of labor.
Question 3 of 5
A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?
Correct Answer: B
Rationale: The correct answer is B: Keep the collection device below the level of the client's chest. This is important to ensure proper drainage and prevent backflow or air from entering the pleural space. Placing the collection device below the chest allows gravity to assist in drainage. Clamping the tube while ambulating (choice A) can lead to increased pressure in the chest, risking complications. Coiling the tubes (choice C) may cause kinks, obstructing drainage. Positioning the client flat (choice D) can lead to leaks in the tubing due to elevated pressure.
Question 4 of 5
When prioritizing client care after receiving change-of-shift report, which of the following clients should the nurse plan to see first?
Correct Answer: D
Rationale: The correct answer is D because a client who is experiencing shortness of breath may be in a critical condition requiring immediate intervention to prevent respiratory distress or failure. This is a high-priority issue that needs prompt assessment and intervention to ensure the client's safety. A: A client awaiting transport for an abdominal x-ray is not in an immediate life-threatening situation. B: A client with a prescription for discharge can typically wait as the discharge process can be coordinated by other healthcare team members. C: A client who received oral pain medication 30 minutes ago is not experiencing an urgent or life-threatening situation, as the medication may take time to alleviate pain.
Question 5 of 5
A client with chronic obstructive pulmonary disease is being taught by a nurse about ways to facilitate eating. Which of the following statements indicates a need for further teaching?
Correct Answer: B
Rationale: The correct answer is B: "I will take my bronchodilators after meals." Taking bronchodilators after meals can decrease their effectiveness due to delayed absorption. Step 1: Bronchodilators should be taken before meals to open airways for better breathing. Step 2: Resting before meals (A) can reduce shortness of breath. Eating small meals (C) can prevent overeating and aid digestion. Choosing non-gas forming foods (D) can reduce bloating.