ATI NUR 135 Exam 1

Correct Answer: B) Conscious sedation

Explanation:

Conscious sedation is a type of anesthesia that allows the patient to remain awake and aware but in a relaxed and calm state. It is typically used for minor procedures or diagnostic tests, where the patient needs to be able to respond to instructions but does not experience discomfort. Medications are administered to relieve anxiety and pain without causing a complete loss of consciousness.

Why Other Options Are Incorrect:

A: General anesthesia

General anesthesia induces a deep sleep or unconscious state, where the patient is not aware of their surroundings or the procedure. It is used for more invasive surgeries where complete unconsciousness is required.

C: Local anesthesia

Local anesthesia numbs a specific area of the body to block sensation during a procedure. While the patient remains awake and alert, they may not feel pain in the targeted area, but local anesthesia does not have the calming or sedative effects of conscious sedation.

D: Epidural anesthesia

Epidural anesthesia is typically used during childbirth or certain surgeries and involves the administration of anesthetic agents into the epidural space in the spine. It can block pain but does not necessarily keep the patient relaxed in the same way as conscious sedation.

Summary:

The correct answer is B) Conscious sedation, which allows patients to stay awake and relaxed, making it ideal for less invasive procedures that still require the patient to remain responsive.

The correct answer is C. Pulmonary congestion.

Explanation:

Left-sided heart failure occurs when the left ventricle is unable to pump blood efficiently to the body, causing blood to back up into the lungs. This results in pulmonary congestion, which can lead to symptoms like shortness of breath, coughing, wheezing, and orthopnea (difficulty breathing when lying down). Pulmonary edema, or fluid accumulation in the lungs, is a common manifestation of left-sided heart failure.

Why the other options are incorrect:

A. Peripheral edema: Peripheral edema, which refers to swelling in the lower extremities, is more characteristic of right-sided heart failure or biventricular heart failure (a combination of both left and right heart failure). It occurs due to fluid backing up in the veins and tissues outside of the lungs.

B. Jugular vein distension: Jugular vein distension (JVD) is a common sign of right-sided heart failure, where blood backs up into the systemic venous system, causing the veins in the neck to visibly bulge. While JVD can also occur in left-sided heart failure, it is more prominent in right-sided heart failure.

D. Hepatomegaly: Hepatomegaly (enlarged liver) is typically seen in right-sided heart failure due to the backup of blood into the abdominal veins, which can lead to congestion of the liver. It is less directly associated with left-sided heart failure.

Summary:

Pulmonary congestion (C) is the hallmark symptom of left-sided heart failure due to fluid backing up into the lungs. Symptoms like peripheral edema, jugular vein distension, and hepatomegaly are more closely associated with right-sided heart failure.

Correct Answer: B) The patient is prepared for surgery

Explanation:

The preoperative phase refers to the period before surgery. During this phase, the patient is prepared for the surgery in various ways. This includes completing necessary medical tests, discussing the surgical procedure with the surgical team, administering preoperative medications if needed, and ensuring the patient is physically and emotionally ready for surgery. This phase ends when the patient is taken to the operating room.

Why Other Options Are Incorrect:

A: The patient recovers from anesthesia

Recovery from anesthesia occurs during the postoperative phase after surgery has been completed.

C: The patient undergoes surgery

The actual surgery takes place during the intraoperative phase, not the preoperative phase.

D: The patient is sent home

The patient is typically sent home after the postoperative phase, once they have recovered enough from surgery and anesthesia to be discharged.

Summary:

The preoperative phase is focused on preparing the patient for surgery, which is option B. This includes ensuring the patient is ready physically and emotionally for the upcoming procedure.

Correct Answer: B. Dilating veins and, at higher doses, arteries

Explanation:

Nitroglycerin is used primarily to treat angina by dilating blood vessels. It works by relaxing the smooth muscles of the veins and, at higher doses, also dilates arteries. This leads to a reduction in preload (the amount of blood returning to the heart) and afterload (the resistance the heart must work against to pump blood). By reducing these two factors, nitroglycerin decreases the workload on the heart and increases blood flow to the heart muscle, improving oxygen delivery and reducing the chest pain associated with angina.

Why the other options are incorrect:

A. Increasing heart rate to improve oxygen delivery:

Nitroglycerin does not increase heart rate. In fact, it may have a slight effect on lowering heart rate as it reduces the workload of the heart. Increased heart rate is typically a response to exercise or stress, but not to nitroglycerin administration.

C. Reducing platelet aggregation:

Nitroglycerin does not have a direct effect on platelet aggregation. Platelet aggregation inhibitors, such as aspirin, are used to prevent blood clots, but nitroglycerin primarily functions as a vasodilator.

D. Slowing conduction through the AV node:

Nitroglycerin does not primarily affect conduction through the atrioventricular (AV) node. This effect is more related to medications such as beta-blockers or calcium channel blockers, which are used to slow heart rate and conduction. Nitroglycerin's main action is vasodilation.

Summary:

Nitroglycerin treats angina by dilating veins (reducing preload) and, at higher doses, arteries (reducing afterload), which lowers the heart's workload and improves oxygen delivery to the heart muscle. It does not increase heart rate, affect platelet aggregation, or slow AV node conduction, which are the actions of other drugs.

Correct Answer: B) Chest trauma

Explanation:

Respiratory acidosis occurs when there is a build-up of carbon dioxide (CO2) in the blood due to impaired respiratory function, which causes the blood to become too acidic. The body compensates for this by trying to remove CO2, but if the lungs cannot expel enough, acidosis develops.

Chest Trauma:

Chest trauma, such as a rib fracture or injury to the lungs, can impair the ability to breathe effectively, leading to hypoventilation (reduced ventilation). This results in CO2 retention, which causes respiratory acidosis. When the body cannot expel CO2 efficiently, the CO2 levels in the blood increase, lowering the blood pH and leading to acidosis.

Why Other Options are Incorrect:

A: Hyperventilation

Hyperventilation refers to rapid or deep breathing, which increases the exhalation of CO2. This would typically lead to respiratory alkalosis (a condition where blood pH increases due to the loss of CO2), not acidosis.

C: Excess bicarbonate intake

Excess bicarbonate intake would not cause respiratory acidosis. Instead, it could contribute to metabolic alkalosis, as bicarbonate is a base that raises the pH of the blood.

D: Pregnancy

Pregnancy can lead to respiratory alkalosis due to increased respiratory rate and more efficient removal of CO2. This condition is generally not associated with respiratory acidosis, though in some rare cases, complications like pulmonary disease can occur that may lead to acidosis.

Summary:

The most common cause of respiratory acidosis is chest trauma (option B), which impairs the lungs' ability to expel CO2, leading to its accumulation in the bloodstream. Other conditions like hyperventilation and excess bicarbonate intake are more likely to cause respiratory alkalosis and metabolic alkalosis, respectively.

Correct Answer: B) 7.35-7.45

Explanation:

Blood pH is a measure of how acidic or alkaline the blood is. The body maintains a tightly regulated pH within this range to ensure proper cellular function and metabolism.

Normal Range for Blood pH:

The normal pH range for blood is between 7.35 and 7.45, which is slightly alkaline. Maintaining this narrow range is crucial for many physiological processes, as enzymes and proteins function best at this pH.

Why Other Options are Incorrect:

A: 6.8-7.2

This pH range is too acidic and would be considered dangerous for the body. A blood pH this low suggests acidosis, which can lead to severe health problems such as organ dysfunction and even coma.

C: 7.5-8.0

This pH range is too alkaline for blood. A blood pH this high suggests alkalosis, which can also cause severe issues like muscle spasms, breathing difficulties, and electrolyte disturbances.

D: 8.0-8.5

This range is far too alkaline for blood, and would be life-threatening if sustained. Such a high pH would impair enzyme activity and disrupt normal bodily functions.

Summary:

The normal blood pH range is 7.35-7.45, which is slightly alkaline. Deviations outside of this range can lead to conditions like acidosis or alkalosis, both of which can be harmful to body function and require medical intervention.

The correct answer is: A) Assessment.

Explanation:

The nursing process consists of five key steps: Assessment, Diagnosis (Analysis), Planning, Implementation, and Evaluation (ADPIE).

Assessment is the first step, where the nurse gathers objective and subjective data about the client’s condition. In this scenario, the nurse observes that the client appears disheveled, frightened, and is talking to someone who is not there, which indicates potential hallucinations or a mental health concern.

Why the Other Options Are Incorrect:

Evaluation:

Occurs at the end of the nursing process to determine if interventions were effective. Since the nurse is simply observing the client at this point, this is not the evaluation phase.

Analysis (Diagnosis):

This step involves interpreting the collected assessment data to form a nursing diagnosis. While the observations might contribute to a diagnosis, the nurse is still gathering information rather than analyzing it.

Planning:

Involves developing interventions and goals based on the assessment and diagnosis. Since no care plan is being created yet, this is not the correct step.

Summary:

The nurse is collecting data through observation, which is part of Assessment—the first step of the nursing process. The other steps involve interpreting, planning, or evaluating care, which comes later.

The correct answer is: B. Excess fluid volume related to decreased cardiac outpu

Explanation:

A 3 kg weight gain in a short period, such as three days, is a significant sign of fluid retention, which is commonly associated with heart failure. In heart failure, the heart's ability to pump effectively is impaired, leading to decreased cardiac output. As a result, the kidneys receive less blood flow and activate mechanisms (such as the renin-angiotensin-aldosterone system) to retain fluid and sodium, exacerbating fluid buildup in the body. The appropriate nursing diagnosis for this situation would be:

Excess fluid volume related to decreased cardiac output, which addresses the accumulation of fluid due to impaired heart function.

Why the Other Options Are Incorrect:

A. Activity intolerance related to fatigue: While fatigue and activity intolerance are common in heart failure, the 3 kg weight gain points more directly to fluid retention, which is better addressed by the Excess fluid volume diagnosis.

C. Acute pain related to myocardial ischemia: Acute pain related to myocardial ischemia would be more applicable if the patient were experiencing chest pain or angina, which is not the main symptom suggested by fluid retention in this case.

D. Risk for infection related to weakened immune response: There is no clear indication from the information provided that the patient is at risk for infection, so this diagnosis is not directly relevant to the symptoms described.

Key Takeaway:

The most appropriate diagnosis is Excess fluid volume related to decreased cardiac output due to the patient's significant weight gain, which is indicative of fluid retention often seen in heart failure.

The correct answer is: C) Managing patient care and documentation outside the sterile field.

Explanation:

The circulating nurse plays a vital role in the operating room, ensuring that the surgical team has everything needed for a successful surgery while maintaining a safe and efficient environment. The circulating nurse is responsible for tasks outside the sterile field, such as obtaining supplies, managing the environment, ensuring the surgical team has the necessary tools, and maintaining proper documentation throughout the procedure. This includes tracking the patient's status, managing sterile instruments, and handling any paperwork or forms required during the surgery. The circulating nurse also coordinates communication between the sterile field and others outside the operating room, ensuring everything runs smoothly.

Why the other options are incorrect:

A) Directly assisting the surgeon with instruments: This role is typically filled by the scrub nurse or surgical technologist. They are responsible for passing instruments and assisting the surgeon directly within the sterile field.

B) Maintaining the sterile field and passing instruments: Again, this is the responsibility of the scrub nurse or surgical technologist. The circulating nurse ensures the sterile field remains intact but does not actively participate in passing instruments.

D) Administering anesthesia and monitoring the patient: Administering anesthesia and monitoring the patient’s physiological responses during surgery are tasks carried out by the anesthesiologist or nurse anesthetist, not the circulating nurse.

Summary:

The primary role of the circulating nurse is to manage patient care and documentation outside the sterile field, ensuring that the surgical team has the resources they need and maintaining a safe and organized environment during surgery.