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Ati advanced med surg proctored exam
Ati advanced med surg proctored exam
Total Questions : 76
Showing 10 questions Sign up for moreA nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and Intervention?
Explanation
A. Paralytic ileus can occur due to stress or injury, but it is not the most immediate threat to life in a burn victim.
B. Burns to the head, neck, and chest can cause rapid swelling and potential airway compromise. Ensuring a patent airway is always the top priority in emergency care, especially in cases involving inhalation injuries or facial burns.
C. Infection is a serious concern in burn clients, particularly as the healing process progresses, but it is not the most immediate life-threatening issue at the time of admission.
D. Fluid imbalance is a critical concern in burn patients due to fluid shifts, but it follows airway management in terms of emergency prioritization according to the ABCs (Airway, Breathing, Circulation) of trauma care.
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?
Explanation
A. Vomiting may indicate distress but does not pose an immediate threat to life and is not the most urgent concern in an anaphylactic reaction.
B. Stridor is a high-pitched, wheezing sound caused by disrupted airflow, indicating upper airway obstruction. This is a medical emergency and requires immediate intervention to maintain airway patency, making it the top priority.
C. Urticaria (hives) is a common skin manifestation of an allergic reaction but is not life-threatening on its own.
D. Hypotension is a serious sign of anaphylaxis, but airway compromise (stridor) takes precedence according to the ABCs of emergency care.
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury?
Explanation
A. Initiating fluid resuscitation is a vital component of burn management during the resuscitation phase, but it follows airway stabilization in priority.
B. Inserting an indwelling urinary catheter is important for monitoring fluid output and kidney function, but it is not the immediate priority.
C. Pain management is essential in burn care, but it is not the most urgent intervention during the initial phase of care.
D. According to the ABCs of emergency care (Airway, Breathing, Circulation), securing the airway is always the first priority, especially in clients with burns to the chest and upper body where airway edema and inhalation injury are likely.
A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?
Explanation
A. Checking pedal pulses assesses circulation but will not help identify the cause of muscle spasms in this context.
B. Muscle spasms following a thyroidectomy may indicate hypocalcemia, a common complication due to accidental removal or damage to the parathyroid glands during surgery. This electrolyte imbalance can lead to neuromuscular excitability and tetany, which requires prompt recognition and treatment.
C. Requesting a relaxant may mask symptoms without addressing the underlying cause, delaying appropriate treatment.
D. Administering potassium is not appropriate unless hypokalemia is confirmed; muscle spasms in this scenario are more likely due to low calcium, not potassium.
A nurse is caring for a client who has been trending with elevated intracranial pressure (ICP) readings for some time. Which of the following findings should the nurse identify as signs indicating Cushing's Triad? (Select all that apply.)
Explanation
A. Increased ammonia levels are associated with hepatic encephalopathy, not increased ICP or Cushing's Triad.
B. It is one of the three classic signs of Cushing's Triad, which indicates late increased ICP and possible brain herniation.
C. Bradycardia is a hallmark sign of Cushing's Triad and reflects brainstem dysfunction due to increased ICP.
D. Slurred speech may occur with increased ICP but is not a component of Cushing's Triad.
E. Positive Kernig's sign indicates meningeal irritation, such as in meningitis, not increased ICP or Cushing's Triad.
A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place with wet suction. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
Explanation
A. Continuing to monitor the client is not appropriate because the lack of bubbling in the suction control chamber indicates that the expected negative pressure may not be present.
B. Adding more water is not the priority until verifying that the suction system is functioning correctly and that there are no leaks in the tubing.
C. Milking the chest tube is typically reserved for situations when there is evidence of a blockage from clots; however, the absence of bubbling is more indicative of a suction malfunction rather than a clogged tube.
D. The lack of bubbling in the suction control chamber suggests that negative pressure may not be maintained, so the nurse should first ensure the suction regulator is set correctly and inspect the tubing for any disconnections or leaks that could disrupt the system's function.
A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. Use all the steps.)
Explanation
A (Airway): Open the airway using a jaw-thrust maneuver is the first action to ensure the airway is patent, especially important in trauma to avoid cervical spine injury.
B (Breathing): Determine effectiveness of ventilator efforts comes next to assess if the client is ventilating adequately.
C (Circulation): Establish IV access is part of restoring and maintaining circulation, allowing for fluid resuscitation or medication administration.
D (Disability): Perform a Glasgow Coma Scale assessment evaluates neurological function to determine the level of consciousness.
E (Exposure): Remove clothing for a thorough assessment ensures the nurse can identify all injuries and prevent missing any life-threatening conditions.
A nurse is instructing a female client on obtaining a clean catch urine sample. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
A. While menstruation can potentially contaminate the sample, it is still possible to collect a clean catch sample during menstruation if proper technique is used; thus, this statement is not entirely accurate.
B. This is the proper clean catch technique—starting the stream helps flush out any contaminants from the urethra, and then the midstream portion is collected for testing.
C. Urine samples should be sent to the lab promptly while still fresh, or refrigerated if there will be a delay. Letting it cool to room temperature can alter test results.
D. Wiping from front to back is correct to reduce contamination from the perineal area; wiping from back to front increases the risk of introducing bacteria from the rectal area.
A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include In the plan?
Explanation
A. Deep breathing is important, but it should be encouraged more frequently than every 4 hours to prevent respiratory complications.
B. Hyperextending the client's neck is contraindicated after a thyroidectomy as it can cause tension on the surgical site and disrupt healing.
C. The head of the bed should be elevated, not flat, to reduce swelling and promote comfort.
D. Monitoring the client’s voice frequently helps detect early signs of recurrent laryngeal nerve damage, which can cause hoarseness or airway obstruction after thyroid surgery.
A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?
Explanation
A. Having a pacemaker is not an absolute contraindication for kidney transplant, though it requires careful evaluation.
B. Active substance abuse, including alcohol use disorder, is generally considered a contraindication for kidney transplantation due to concerns about adherence to medical regimens and potential for complications.
C. Being a breast cancer survivor for 8 years is usually not a contraindication if the client has been cancer-free for a significant period and is deemed stable.
D. Age 65 years is not an absolute contraindication; many older adults can be candidates for transplant based on overall health status rather than age alone.
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