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ATI RN Adult Medical Surgical Online Practice 2023 A
1. A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
- A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
- B. Assess for an increase in temperature.
- C. Check the oximeter.
- D. Monitor for manifestations of increased intracranial pressure.
Correct answer: C
Rationale: When caring for a client who had an evacuation of a subdural hematoma, the nurse's priority is to check the oximeter. Monitoring oxygen saturation is crucial to ensure adequate tissue oxygenation, especially after such a procedure. This assessment helps in early detection of hypoxemia, which can be detrimental to the client's recovery. While observing for CSF leaks, assessing for temperature changes, and monitoring for signs of increased intracranial pressure are important, checking the oximeter takes precedence to address immediate oxygenation needs.
2. When reviewing the provider's orders, a nurse recognizes that clarification is needed for which of the following medications in a client experiencing an exacerbation of asthma?
- A. Propranolol
- B. Theophylline
- C. Montelukast
- D. Prednisone
Correct answer: A
Rationale: The correct answer is Propranolol. Propranolol is a beta-blocker that can potentially exacerbate asthma symptoms due to its mechanism of action. It can cause bronchoconstriction, which is harmful for a client experiencing an asthma exacerbation. Theophylline, Montelukast, and Prednisone are commonly used in the treatment of asthma exacerbations and would not typically require clarification in this context.
3. A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?
- A. Clamp the tube when the client is ambulating.
- B. Keep the collection device below the level of the client's chest.
- C. Carefully coil the tubes to prevent kinking.
- D. Position the client flat to avoid leaks in the tubing.
Correct answer: B
Rationale: Keeping the collection device below the level of the client's chest ensures proper drainage and prevents backflow of fluid into the patient's chest. This position allows gravity to assist in the drainage process. Clamping the tube when the client is ambulating can cause a buildup of pressure in the chest drainage system, potentially leading to complications. Carefully coiling the tubes is important to prevent obstructions and kinks that could impede the flow of drainage. Positioning the client flat may not be ideal as it could hinder proper drainage and increase the risk of leaks in the tubing.
4. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
- A. Urticaria
- B. Stridor
- C. Vomiting
- D. Hypotension
Correct answer: B
Rationale:
5. During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow to normal breaths alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct answer: A
Rationale: Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea (temporary cessation of breathing). This pattern is often seen in clients near the end of life or with certain medical conditions affecting the respiratory control center in the brain. The alternating deep and shallow breaths can be distressing for both the client and caregivers. It is crucial for the nurse to recognize this pattern to provide appropriate care and support to the client and their family during this challenging time.
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