ATI MATERNAL NEWBORN PROCTORED EXAM
1. The nurse is preparing a patient for surgery. Which goal is a
priority for assessing the patient before surgery?
a. Plan for care after the procedure.
b. Establish a patient’s baseline of normal function.
c. Educate the patient and family about the procedure.
d. Gather appropriate equipment for the patient’s needs.
ANS: B
The goal of the preoperative assessment is to identify a patient’s normal
preoperative function and the presence of any risks to recognize, prevent, and
minimize possible postoperative complications. Gathering appropriate
equipment, planning care, and educating the patient and family are all
important interventions that must be provided for the surgical patient; they are
part of the nursing process but are not the priority reason/goal for completing
an assessment of the surgical patient.
2. The nurse is completing a medication history for the surgical patient
in preadmission testing. Which medication should the nurse instruct the
patient to hold (discontinue) in preparation for surgery according to
protocol?
a. Warfarin
b. Vitamin C
c. Prednisone
d. Acetaminophen
ANS: A
Medications such as warfarin or aspirin alter normal clotting factors and thus
increase the risk of hemorrhaging. Discontinue at least 48 hours before
,surgery. Acetaminophen is a pain reliever that has no special implications for
surgery. Vitamin C actually assists in wound healing and has no special
implications for surgery. Prednisone is a corticosteroid, and dosages are often
temporarily increased rather than held.
3. The nurse is prescreening a surgical patient in the preadmission
testing unit. The medication history indicates that the patient is
currently taking an anticoagulant. Which action should the nurse take
when consulting with the health care provider?
a. Ask for a radiological examination of the chest.
b. Ask for an international normalized ratio (INR).
c. Ask for a blood urea nitrogen (BUN).
d. Ask for a serum sodium (Na).
ANS: B
INR, PT (prothrombin time), APTT (activated partial thromboplastin time), and
platelet counts reveal the clotting ability of the blood. Anticoagulants can be
utilized for different conditions, but its action is to increase the time it takes for
the blood to clot. This action can put the surgical patient at risk for bleeding
tendencies.
Typically, if at all possible, this medication is held several days before a
surgical procedure to decrease this risk. Chest x-ray, BUN, and Na are
diagnostic screening tools for surgery but are not specific to anticoagulants.
4. The nurse is encouraging the postoperative patient to utilize diaphragmatic
breathing. Which priority goal is the nurse trying to achieve?
a. Manage pain
b. Prevent atelectasis
c. Reduce healing time
d. Decrease thrombus formation
ANS: B
After surgery, patients may have reduced lung volume and may require
greater effort to cough and deep breathe; inadequate lung expansion can lead
, to atelectasis and pneumonia. Purposely utilizing diaphragmatic breathing
can decrease this risk. During general anesthesia, the lungs are not fully
inflated during surgery and the cough reflex is suppressed, so mucus collects
within airway passages. Diaphragmatic breathing does not manage pain; in
some cases, if splinting and pain medications are not given, it can cause pain.
Diaphragmatic breathing does not reduce healing time or decrease thrombus
formation. Better, more effective interventions are available for these
situations.
5. The nurse is caring for a postoperative patient on the medical-surgical
floor. Which activity will the nurse encourage to prevent venous stasis and
the formation of thrombus?
a. Diaphragmatic breathing
b. Incentive spirometry
c. Leg exercises
d. Coughing
ANS: C
After general anesthesia, circulation slows, and when the rate of blood
slows, a greater tendency for clot formation is noted. Immobilization results
in decreased muscular contractions in the lower extremities; these
promote venous stasis. Coughing, diaphragmatic breathing, and incentive
spirometry are utilized to decrease atelectasis and pneumonia.
6. The nurse is caring for a preoperative patient. The nurse teaches the
principles and demonstrates leg exercises for the patient. The patient is
unable to perform leg exercises correctly. What is the nurse’s best next
step?
a. Encourage the patient to practice at a later date.
b. Assess for the presence of anxiety, pain, or fatigue.
c. Ask the patient why exercises are not being done.
d. Evaluate the educational methods used to educate the patient.
1. The nurse is preparing a patient for surgery. Which goal is a
priority for assessing the patient before surgery?
a. Plan for care after the procedure.
b. Establish a patient’s baseline of normal function.
c. Educate the patient and family about the procedure.
d. Gather appropriate equipment for the patient’s needs.
ANS: B
The goal of the preoperative assessment is to identify a patient’s normal
preoperative function and the presence of any risks to recognize, prevent, and
minimize possible postoperative complications. Gathering appropriate
equipment, planning care, and educating the patient and family are all
important interventions that must be provided for the surgical patient; they are
part of the nursing process but are not the priority reason/goal for completing
an assessment of the surgical patient.
2. The nurse is completing a medication history for the surgical patient
in preadmission testing. Which medication should the nurse instruct the
patient to hold (discontinue) in preparation for surgery according to
protocol?
a. Warfarin
b. Vitamin C
c. Prednisone
d. Acetaminophen
ANS: A
Medications such as warfarin or aspirin alter normal clotting factors and thus
increase the risk of hemorrhaging. Discontinue at least 48 hours before
,surgery. Acetaminophen is a pain reliever that has no special implications for
surgery. Vitamin C actually assists in wound healing and has no special
implications for surgery. Prednisone is a corticosteroid, and dosages are often
temporarily increased rather than held.
3. The nurse is prescreening a surgical patient in the preadmission
testing unit. The medication history indicates that the patient is
currently taking an anticoagulant. Which action should the nurse take
when consulting with the health care provider?
a. Ask for a radiological examination of the chest.
b. Ask for an international normalized ratio (INR).
c. Ask for a blood urea nitrogen (BUN).
d. Ask for a serum sodium (Na).
ANS: B
INR, PT (prothrombin time), APTT (activated partial thromboplastin time), and
platelet counts reveal the clotting ability of the blood. Anticoagulants can be
utilized for different conditions, but its action is to increase the time it takes for
the blood to clot. This action can put the surgical patient at risk for bleeding
tendencies.
Typically, if at all possible, this medication is held several days before a
surgical procedure to decrease this risk. Chest x-ray, BUN, and Na are
diagnostic screening tools for surgery but are not specific to anticoagulants.
4. The nurse is encouraging the postoperative patient to utilize diaphragmatic
breathing. Which priority goal is the nurse trying to achieve?
a. Manage pain
b. Prevent atelectasis
c. Reduce healing time
d. Decrease thrombus formation
ANS: B
After surgery, patients may have reduced lung volume and may require
greater effort to cough and deep breathe; inadequate lung expansion can lead
, to atelectasis and pneumonia. Purposely utilizing diaphragmatic breathing
can decrease this risk. During general anesthesia, the lungs are not fully
inflated during surgery and the cough reflex is suppressed, so mucus collects
within airway passages. Diaphragmatic breathing does not manage pain; in
some cases, if splinting and pain medications are not given, it can cause pain.
Diaphragmatic breathing does not reduce healing time or decrease thrombus
formation. Better, more effective interventions are available for these
situations.
5. The nurse is caring for a postoperative patient on the medical-surgical
floor. Which activity will the nurse encourage to prevent venous stasis and
the formation of thrombus?
a. Diaphragmatic breathing
b. Incentive spirometry
c. Leg exercises
d. Coughing
ANS: C
After general anesthesia, circulation slows, and when the rate of blood
slows, a greater tendency for clot formation is noted. Immobilization results
in decreased muscular contractions in the lower extremities; these
promote venous stasis. Coughing, diaphragmatic breathing, and incentive
spirometry are utilized to decrease atelectasis and pneumonia.
6. The nurse is caring for a preoperative patient. The nurse teaches the
principles and demonstrates leg exercises for the patient. The patient is
unable to perform leg exercises correctly. What is the nurse’s best next
step?
a. Encourage the patient to practice at a later date.
b. Assess for the presence of anxiety, pain, or fatigue.
c. Ask the patient why exercises are not being done.
d. Evaluate the educational methods used to educate the patient.
