Comprehensive predictorretake with ngn
1. Thepostanesthesiacareunit(PACU)nursetransportstheinpatientsurgicalpatienttothemedical-surgicalfloor.Beforeleavingthefloor,themedical-surgicalnurseobtainsacompletesetof
vitalsigns.Whatistherationale for this nursing action?
a. Thisisdonetocompletethefirstactioninahead-to-toeassessment.
Thisisdonetocompareandmonitorforvitalsignvariationduring
b. transport.
Thisisdonetoensurethatthemedical-surgicalnursechecksonthe
c. postoperativepatient.
Thisisdonetofollowhospitalpolicyandprocedureforcareofthe
d. surgicalpatient.
ANS:B
BeforethePACUnurseleavestheacutecarearea,thestaffnurseassumingcareforthepatienttakesacompletesetofvitalsignstocomparewithPACU findings.Minorvitalsignvariationsnormallyoccur after
transporting the patient.The PACU nursereviewsthepatient’sinformation with the medical-surgical nurse, including thesurgicalandPACUcourse,physicianorders,and thepatient’scondition.While vitalsignsmay ormaynot be the first
actionina head-to-toeassessment,thisisnottherationaleforthissituation.While followingpolicy orascertainingthatthefloornursecheckson thepatient are goodreasonsforsafecare,theyarenotthebest rationale for obtaining vital
signs.
2. Thenurseiscaringforapatientwhowillundergoaremovalofalunglobe.Whichlevelofcarewillthepatientrequireimmediatelypostprocedure?
a. Acutecare—medical-surgicalunit
b. Acutecare—intensivecareunit
c. Ambulatorysurgery
d. Ambulatorysurgery—extendedstay
ANS:B
Patients undergoing extensive surgery and requiring anesthesia of long duration recover slowly. If a patient is undergoing majorsurgery such as a procedure on the lung, a stay in the hospital and specifically in
theintensive care unit is required tomonitorfor potential risks towell-being. This patient would requiremore care than can be providedon a medical-surgical unit. It is not appropriatefor this type of patient to go home
after theprocedureortostayin anextendedstayareaof an ambulatorysurgeryareabecause ofthecomplexityandassociatedrisks.
,NEW 2023 ATI RN COMPREHENSIVE PREDICTOR RETAKE WITH NGN
Comprehensive predictorretake with ngn
3. Thenurseiscaringforagroupofpatients.Whichpatientwillthenurseseefirst?
a. Apatientwhohadcataractsurgeryiscoughing.
Apatientwhohadvascularrepairoftherightlegisnotdoingrightleg
b. exercises.
Apatientafterkneesurgeryiswearingintermittentpneumatic
c. compressiondevicesandreceivingheparin.
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, NEW 2023 ATI RN COMPREHENSIVE PREDICTOR RETAKE WITH NGN
Comprehensive predictorretake with ngn
Apatientaftersurgeryhasvitalsignstakenevery15minutestwice,
d. every30minutestwice,hourlyfor2hoursthenevery4hours.
ANS:A
Forpatientswhohavehadeye,intracranial,orspinalsurgery,coughingmaybecontraindicatedbecauseofthepotentialincreaseinintraocularorintracranialpressure.Thenursewillneedtoseethis patient first to controlthecough and intraocular
pressure. All the rest are normal postoperative patients. Leg exercise should not beperformed on the operative leg with vascular surgery. Apatient
afterkneesurgeryshouldreceiveheparinandbewearingintermittentpneumaticcompressiondevices;whilethenursewillcheckonthepatient,it doesnothavetobefirst.Monitoringvitalsignsafter surgery is required and this is the standard
schedule.
4. Thenursedemonstrates postoperativeexercisesfora patient.In which order will thenurse instruct thepatientto performtheexercise s? 1.Turning
2. Breathing
3. Coughing
4. Legexercises
a. 4,1,2,3
b. 1,2,3,4
c. 2,3,4,1
d. 3,1,4,2
ANS:A
The sequenceof exercisesisleg exercises,turning,breathing, andcoughing. MULTIPLE RESPONSE
1. Thenurseisparticipatingina“time-out.”Inwhichactivitieswillthenursebeinvolved?(Selectallthatapply.)
a. Verifythecorrectsite.
b. Verifythecorrectpatient.
c. Verifythecorrectprocedure.
d. Perform“time-out”aftersurgery.