ATI RN
NP125 Med Surg Exam Questions
Extract:
Question 1 of 5
Which action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)?
Correct Answer: B
Rationale: Checking plantar and dorsiflexion assesses neurological status requiring nursing expertise and cannot be delegated to UAP. Log rolling every 2 hours maintains spinal alignment post-laminectomy, a straightforward, standardized task suitable for experienced UAP. PCA assessment involves evaluating pain control methods, which require critical nursing judgments and is not appropriate to delegate. Determining readiness to ambulate involves comprehensive assessment skills, evaluating multiple factors like pain, strength, and hemodynamic stability, beyond UAP's scope of practice.
Question 2 of 5
A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which statement should the nurse include in discharge teaching?
Correct Answer: C
Rationale: Removing the external fixator for a shower could compromise stabilization of the fracture. External fixators are designed to be left in place to maintain proper alignment and provide structural support for healing bones. Removing the device could introduce unnecessary risks, including increased mobility and potential damage to the fracture site. Prolonged bed rest is not indicated for patients with external fixation devices unless medically necessary. Prolonged immobility can lead to complications such as deep vein thrombosis, muscle atrophy, or joint stiffness. Mobilization should be encouraged as tolerated to support recovery. Proper cleaning of pin insertion sites prevents infection, a major risk with external fixation devices. Using sterile technique to clean the sites daily reduces bacterial colonization. Monitoring for signs of infection such as redness or drainage is critical to avoid osteomyelitis or systemic spread. Prophylactic antibiotics are typically administered perioperatively but are not continued until device removal unless there are specific complications. Prolonged antibiotic use can lead to antimicrobial resistance and should only be used as clinically indicated to prevent or treat infection.
Question 3 of 5
When caring for a patient after lumbar spinal surgery, the nurse would immediately report which finding to the healthcare provider?
Correct Answer: A
Rationale: Loss of sensation to the perineum, buttocks, inner thighs, and back of the legs may indicate cauda equina syndrome, a surgical emergency. This condition involves compression of the spinal nerve roots and can lead to permanent neurological damage if not promptly addressed. Immediate medical intervention is critical. Nausea and delayed voiding postoperatively are common, potentially due to anesthesia effects or limited mobility. While these findings warrant monitoring, they do not typically indicate an urgent issue unless prolonged or associated with other complications. Mild low back pain is expected after lumbar spinal surgery due to manipulation of spinal structures. Pain management with prescribed analgesics and gradual mobilization is part of the standard postoperative care plan, and it does not usually necessitate immediate reporting. A single episode of emesis can result from anesthesia effects or medication. Unless accompanied by persistent vomiting, signs of aspiration, or electrolyte imbalances, isolated emesis is not typically urgent and should be managed with antiemetics if necessary.
Question 4 of 5
Insulin lispro (Humalog) is what type of insulin?
Correct Answer: A
Rationale: Insulin lispro (Humalog) is a rapid-acting insulin that begins to lower blood glucose within 15 minutes of injection, with a peak effect occurring in 30 minutes to 1 hour. It mimics the insulin release following a meal, allowing for better postprandial glucose control. Intermediate-acting insulin, such as NPH, has an onset of 1.5 to 4 hours and provides blood glucose control over an extended period. Insulin lispro does not fit this profile, as it acts quickly and is used for meal-time glucose management. Long-acting insulins, such as glargine or detemir, have no peak and provide basal glucose control for 24 hours or more. Lispro is not suitable for basal control due to its rapid action and short duration.
Question 5 of 5
The nurse is assessing a client with peptic ulcer disease (PUD). Which finding, if observed by the nurse, would require immediate follow-up?
Correct Answer: C
Rationale: Low urine output could be due to dehydration, medication effects, or stress. While it warrants further assessment, it is not typically associated with immediate life-threatening complications in the context of PUD. Vomiting after a meal can occur in PUD due to delayed gastric emptying or irritation. However, it does not immediately indicate a complication requiring urgent follow-up unless accompanied by other symptoms such as severe pain or hematemesis. Blood in the stool may indicate gastrointestinal bleeding, a serious complication of PUD. This finding requires immediate evaluation to determine the source and extent of bleeding, as it can lead to hypovolemic shock if untreated. Abdominal discomfort is common in PUD due to gastric irritation or acid-related issues. While it requires management, it does not typically signal an urgent complication unless associated with other alarming symptoms.