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Exam (elaborations)

ATI Fundamentals Exam
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1. a nurse in a clinical is caring for a middle age adult who states, "the doctor says that since I am at an average risk for colon cancer, I should have a routine screening. what does that involve?" which of the following responses should the nurse make? A. "I'll get a blood sample from you...

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  • May 5, 2024
  • 9
  • 2023/2024
  • Exam (elaborations)
  • Questions & answers

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  • ati fundamentals exa
  • ati fundamentals ex
  • ati fundamentals e

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  • ATI Fundamentals E
  • ATI Fundamentals E

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ATI RN COMPREHENSIVE EXIT EXAM 1.The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which action will the nurse take to minimize skin breakdown?
a.Encouraging the patient to bathe before surgery
b.Securing attachments to the operating table with foam padding
c.Periodically adjusting the patient during the surgical procedure
d.Measuring the time a patient is in one position during surgery
ANS: B
Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect the patient from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the operating suite table provide protection for the extremities and bony prominences. Bathing before surgery helps to decrease the number of microbes on the skin. Periodically adjusting the patient during
the surgical procedure is impractical and can present a safety issue with regard to maintaining sterility of the field and maintaining an airway. Measuring the time the patient is in one position may help with monitoring the situation but does not prevent skin breakdown.
2.The nurse is assessing a postoperative patient with a history of obstructive sleep apnea for airway obstruction. Which assessment finding will best alert the nurse to this complication?
a.Drop in pulse oximetry readings
b.Moaning with reports of pain
c.Shallow respirations
d.Disorientation
ANS: A
One of the greatest concerns after general anesthesia is airway obstruction, especially in patients with obstructive sleep apnea. A drop in oxygen saturation by pulse oximetry is a sign of airway obstruction in patients with obstructive sleep apnea. Weak pharyngeal/laryngeal muscle tone from anesthetics; secretions in the pharynx, bronchial tree, or trachea; and laryngeal or subglottic edema also contribute to airway obstruction.
In the postanesthetic patient, the tongue is a major cause of airway obstruction. Shallow respirations are indicative of respiratory depression. Moaning and reports of pain are common in all surgical patients and are an expected event. Disorientation is common when first awakening from anesthesia but can be a sign of hypoxia.
3.The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. Which condition does the nurse suspect the patient is experiencing?
a.Malignant hyperthermia
b.Fluid imbalance
c.Hemorrhage
d.Hypoxia
ANS: A
A life-threatening, rare complication of anesthesia is malignant hyperthermia. Malignant hyperthermia causes hypercarbia, tachycardia, tachypnea, premature ventricular contractions, unstable blood pressure, cyanosis, skin mottling, and muscular rigidity. It often occurs during anesthesia induction. Hypoxia would manifest with
decreased oxygen saturation as one of its signs and symptoms. Fluid imbalance would be assessed with intake and output and can manifest with tachycardia and blood pressure fluctuations but does not have muscle rigidity. Hemorrhage can manifest with tachycardia and decreased blood pressure, along with a thready pulse. Usually some sign or symptom of blood loss is noted (e.g., drains, incision, orifice, and abdomen).
4.The nurse is caring for a postoperative patient who has had a minimally invasive carpel tunnel repair. The patient has a temperature of 97° F and is shivering. Which reason will the nurse most likely consider as the primary cause when planning care?
324This study source was downloaded by 100000863148171 from CourseHero.com on 03-22-2023 13:18:36 GMT -05:00
https://www.coursehero.com/file/98592736/ATI-RN-Comprehensive-EXIT-EXamdocx/ a.Anesthesia lowers metabolism.
b.Surgical suites have air currents.
c.The patient is dressed only in a gown.
d.The large open body cavity contributed to heat loss.
ANS: A
The operating suite and recovery room environments are extremely cool. The patient’s anesthetically depressed level of body function results in lowering of metabolism and a fall in body temperature. Although the patient is dressed in a gown and there are air currents in the operating room, these are not the primary reasons for the low temperature. Also, the patient in this type of case does not have a large open body cavity to contribute to heat loss.
5.The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take?
a.Encourage copious amounts of water.
b.Start an additional intravenous (IV) line.
c.Measure and record all intake and output.
d.Weigh the patient and compare with preoperative weight.
ANS: C
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325This study source was downloaded by 100000863148171 from CourseHero.com on 03-22-2023 13:18:36 GMT -05:00
https://www.coursehero.com/file/98592736/ATI-RN-Comprehensive-EXIT-EXamdocx/

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