ATI RN
Introduction to Nursing Final Exam Quizlet Questions
Question 1 of 5
0.9 normal saline solution had been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 12 hours to increase urine output and maintain the client's blood pressure. Upon entering the Justine’s room, the you noted that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?
Correct Answer: B
Rationale: The correct answer is B: Crackles in the lungs. Rapid breathing and coughing can indicate fluid overload, a potential complication of infusing 0.9% saline solution. Crackles in the lungs suggest pulmonary edema, a serious consequence of fluid overload. Assessing for crackles in the lungs is crucial for early detection and intervention. Incorrect Choices: A: Excessive bleeding is not directly related to infusing saline solution. C: Incompatibility of the infusion is unlikely as 0.9% saline is a standard solution. D: Chest pain radiating to the left arm is more indicative of cardiac issues like a heart attack, not fluid overload.
Question 2 of 5
To reduce risk of airborne disease transmission from a client with infectious status in a private room, the nurse should do which of the following control measures?
Correct Answer: D
Rationale: The correct answer is D: Provide special ventilation. Special ventilation systems help to control and reduce the concentration of airborne pathogens in the room, decreasing the risk of disease transmission. This measure is necessary for infection control in private rooms. A: Using a face mask when entering the room may provide some protection, but it is not as effective as special ventilation in reducing airborne pathogen concentration. B: Keeping the door closed can help contain the pathogens within the room but does not address the need for proper ventilation. C: Limiting visitors can help reduce the spread of infection, but it does not directly address airborne transmission control like special ventilation does.
Question 3 of 5
When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be:
Correct Answer: C
Rationale: The correct answer is C: Administering pain medication. In Maslow's hierarchy of needs, physiological needs like pain relief are the most basic and must be addressed first for the client's well-being. Administering pain medication ensures the client's physical comfort and safety, which is crucial before addressing other needs. Allowing the family to see the client (A) and ambulating the client (B) are important but not as urgent as addressing pain. Placing wrist restraints on the client (D) should only be considered if absolutely necessary for the client's safety and should not be the first priority.
Question 4 of 5
When auscultating a client's chest, the nurse assesses a second heart sound (S2). This sound results from:
Correct Answer: D
Rationale: The second heart sound (S2) occurs during the closing of the aortic and pulmonic valves. This closure marks the end of systole and the beginning of diastole. The closure of these valves produces a characteristic "dub" sound. The opening of the mitral and tricuspid valves occurs during diastole, while the opening of the aortic and pulmonic valves happens during systole. Therefore, the correct answer is D, as it accurately reflects the physiological basis of S2. The other choices (A, B, C) are incorrect as they do not align with the specific cardiac events associated with the second heart sound.
Question 5 of 5
Taking the temperature rectally is contraindicated with which of the following clients?
Correct Answer: B
Rationale: The correct answer is B: A client with significant hemorrhoids. Rectal temperature measurement is contraindicated in clients with significant hemorrhoids due to the risk of causing discomfort, pain, and potential bleeding. It can worsen the condition and lead to complications. A: A client who had adenoidectomy - This does not directly affect the rectal temperature measurement process. C: A client who smokes - Smoking does not specifically contraindicate rectal temperature measurement. D: A client with wired jaws - This does not impact the rectal temperature measurement process.