ATI RN
ATI n269 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make?
Correct Answer: A
Rationale: A total laryngectomy involves the removal of the larynx, which can impact both the ability to smell and taste. This is due to the altered airflow and the loss of normal sensory processes. Explaining this to the patient is an appropriate response.
Question 2 of 5
Which is the most common symptom of lung cancer?
Correct Answer: D
Rationale: Persistent cough: This is the correct answer. A persistent cough is the most common symptom of lung cancer, especially in the early stages. The cough may be dry or productive and is often overlooked or mistaken for a chronic respiratory condition.
Question 3 of 5
Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?
Correct Answer: B
Rationale: Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
Question 4 of 5
After observing blood-tinged mucous when suctioning a patient who has just arrived on the medical-surgical unit after a laryngectomy, which action by the nurse is best?
Correct Answer: A
Rationale: Placing the patient in a lateral recovery position is the best immediate action. This position helps facilitate drainage of secretions, especially after a laryngectomy, which can reduce the risk of aspiration and airway obstruction. The blood-tinged mucus may be due to recent surgery and should be monitored for changes.
Question 5 of 5
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action?
Correct Answer: D
Rationale: Checking the drainage for glucose is the most appropriate initial action. Clear drainage from the nasal packing could indicate a CSF leak, which is a complication that can occur after transsphenoidal surgery. CSF contains glucose, so testing for glucose in the drainage will help determine if it is CSF.