ATI RN
ATI RN Custom Med Surg Surgical patient Questions
Extract:
Question 1 of 5
A nurse is caring for a patient who has acute kidney injury. The patient's ABGs are: pH: 7.26, PaCO2: 30 mm Hg, HCO3: 14 mEq/L. Which of the following acid-base imbalances should the nurse identify the patient is experiencing?
Correct Answer: B
Rationale: Low pH (7.26), low HCO3 (14 mEq/L), and low PaCO2 (30 mm Hg) indicate metabolic acidosis, common in kidney injury due to acid accumulation. Other imbalances do not match these values.
Question 2 of 5
A patient with new third-degree burns over 60% of the body is confused and presents with a blood pressure of 79/56 mm Hg, heart rate of 132 beats/min, and respirations of 28 breaths/min with crackles on auscultation. The patient's body temperature is 76° F, and the skin is pale and clammy. Which stage of shock is this patient experiencing?
Correct Answer: C
Rationale: Early reversible shock is indicated by moderate hypotension, tachycardia, and compensatory signs like confusion and crackles. Irreversible shock involves profound organ failure, end-organ dysfunction more severe signs, and preshock normal BP.
Question 3 of 5
A nurse is caring for a client who is receiving a transfusion of packed red blood cells and develops itching and hives. What should be the nurse's first response?
Correct Answer: D
Rationale: Stopping the transfusion immediately prevents further exposure to allergens causing the reaction. Obtaining vital signs, notifying the RN, or administering diphenhydramine are secondary to halting the transfusion to avoid worsening the reaction.
Question 4 of 5
A nurse is providing postoperative care for a patient who has a closed-wound drainage system. Which of the following actions should the nurse perform?
Correct Answer: C
Rationale: Fully re-collapsing the reservoir maintains the vacuum for drainage. Irrigation is not routine, plug replacement timing is incorrect, and daily emptying may be insufficient.
Question 5 of 5
A nurse is caring for a group of patients on an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?
Correct Answer: C
Rationale: Patients receiving enteral feedings via an NG tube are at high risk for aspiration due to impaired swallowing mechanisms and potential misplacement of the tube, which can allow formula to enter the lungs. Colostomies and ileostomies affect lower digestive tracts, not airway protection. Chest tubes address pleural space issues, not aspiration risk.