ATI Medical-Surgical Exam Questions and Answers with Rationales 2022/2023
Question: A male client has just undergone a laryngectomy and has a cuffed
... [Show More] tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
A. Immediately after feeding
B. Just prior to tube feeding
C. Continuous inflation is required
D. Inflation is not required Correct Answer B. Just prior to tube feeding
Rationale:
The cuff should be inflated before the feeding to block the trachea and prevent food from entering (B) if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. (A and D) place the client at risk for aspiration. (C) places the client at risk for tracheal wall necrosis.
Question: During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take?
A. Continue with the shift report and talk to the nurse about the incident at a later time.
B. Ask the nurse to call the house supervisor to see if she must be reassigned.
C. Stop the shift report and remind the nurse that all staff are floated equally.
D. Inform the nurse that her behavior is disruptive to the rest of the staff. Correct Answer A. Continue with the shift report and talk to the nurse about the incident at a later time.
Rationale:
Continuing with the shift report (A) is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private. (B) encourages the nurse to shirk the float assignment. (C) is disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse should be counseled in private (D).
Question: The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding?
A. Myocardial infarction 2 months ago
B. Anorexia and vomiting for the past 2 days
C. Recently diagnosed type 2 diabetes mellitus
D. Skeletal traction for a right hip fracture Correct Answer B. Anorexia and vomiting for the past 2 days [Show Less]