a nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible the client had intermaxillary fixat
Logo

Nursing Elites

ATI RN

ATI Detailed Answer Key Medical Surgical

1. A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

Correct answer: A

Rationale: Preventing aspiration is the priority for a client with intermaxillary fixation following mandibular surgery. Aspiration can occur due to difficulty swallowing or improper positioning, posing a serious risk to the client's respiratory status. It is crucial for the nurse to ensure that the client's airway is clear and that they are positioned correctly to prevent any potential aspiration events.

2. A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?

Correct answer: B

Rationale: When suspecting anaphylaxis, the priority intervention is to assess the client's respiratory status by counting the respiratory rate. Respiratory distress is a hallmark sign of anaphylaxis, and prompt recognition and management are crucial. Administering oxygen may be necessary, but assessing the respiratory rate takes precedence to determine the severity of the reaction and the need for immediate intervention. Inserting an IV line and preparing for intubation are important interventions in managing anaphylaxis but are secondary to ensuring adequate ventilation.

3. A healthcare professional is assessing a client with rheumatoid arthritis. Which assessment finding is most characteristic of this disease?

Correct answer: C

Rationale: Morning stiffness lasting more than 30 minutes is a hallmark symptom of rheumatoid arthritis. This prolonged morning stiffness is typically a distinguishing feature of rheumatoid arthritis compared to other types of arthritis, making it the most characteristic assessment finding for this disease.

4. A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Correct answer: B

Rationale: In myasthenia gravis, a neuromuscular disorder characterized by muscle weakness and fatigue, weakness is a common manifestation due to the immune system attacking the communication between nerves and muscles. Monitoring for weakness is crucial to assess the disease progression and determine the effectiveness of treatment. Confusion is not a typical manifestation of myasthenia gravis. Increased intracranial pressure and increased urinary output are not directly associated with this condition.

5. When teaching a client with chronic obstructive pulmonary disease who will start using fluticasone via MDI twice daily, which instruction should the nurse include?

Correct answer: B

Rationale: It is crucial for clients using inhaled corticosteroids like fluticasone to inspect their mouths daily for signs of oral thrush, a common side effect. Checking the mouth can help identify lesions early, allowing for timely intervention to prevent worsening of the condition. Monitoring heart rate is not specifically required for this medication. Fluticasone is a maintenance medication used to manage COPD, not to relieve acute attacks. Skipping doses, especially in the morning, can lead to inadequate control of COPD symptoms.

Similar Questions

A client has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
A client is postoperative following an intermaxillary fixation due to multiple facial fractures. Which type of equipment should be at the client's bedside?
How does the pain of a myocardial infarction (MI) differ from stable angina?
A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?
A client is vomiting. Which of the following actions should the nurse take first?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses