ATI RN
Introduction to Nursing Questions
Question 1 of 5
A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?
Correct Answer: A
Rationale: The correct action is to slow the IV infusion (choice A) first. The client is exhibiting signs of fluid overload, which can lead to serious complications. Slowing the IV infusion will help decrease the rate of fluid entering the body, alleviating the symptoms. It is important to address this issue promptly to prevent further complications. Sitting the client up in bed (choice B) may help with breathing but does not address the root cause of the symptoms. Removing the IV catheter (choice C) without addressing the fluid overload may not be enough to manage the situation. Calling the primary health care provider (PHCP) (choice D) may cause a delay in addressing the immediate need to slow down the IV infusion.
Question 2 of 5
Nurse Corazon is making initial rounds at the beginning of the shift. She enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the bag is empty. Which of the following solutions readily available on the nursing unit should the she hang until another TPN solution is mixed and delivered to the nursing unit?
Correct Answer: B
Rationale: The correct answer is B: 5% dextrose in water. When a TPN bag is empty, it is important to prevent hypoglycemia by providing a temporary source of glucose until a new TPN solution can be prepared. 5% dextrose in water is the appropriate choice as it provides a low concentration of glucose to maintain blood sugar levels without overloading the patient with excessive dextrose. Option A, 10% dextrose in water, is too concentrated and may cause hyperglycemia in the patient. Option C, 5% dextrose in 0.9% sodium chloride, is not ideal as the patient on TPN does not need additional sodium and chloride in the solution. Option D, None of the above, is incorrect as providing no solution would leave the patient at risk of hypoglycemia.
Question 3 of 5
A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?
Correct Answer: A
Rationale: The correct answer is A because it directly addresses the nursing diagnosis by focusing on the client's ability to identify potassium-rich food sources, which is crucial in managing the risk for injury related to potassium-wasting diuretics. The outcome is specific, measurable, and achievable, aligning with the SMART criteria for goal setting. Choice B is incorrect as it does not specify a measurable action related to potassium-rich foods. Choice C lacks the specificity of identifying the number of potassium-rich food sources. Choice D is incorrect as it does not directly address the nursing diagnosis and focuses on a different aspect of the client's understanding.
Question 4 of 5
Which nursing diagnosis would comply with guidelines set forth by NANDA?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury related to generalized weakness. This diagnosis complies with NANDA guidelines as it is specific, measurable, and based on clinical judgment. It focuses on the potential harm a patient may experience due to their weakness, aligning with NANDA's criteria for nursing diagnoses. The other choices lack specificity and do not directly address the patient's actual health problem. Choice A assumes the cause of ineffective airway clearance without assessment data. Choice B involves psychological factors not directly related to a physiological condition. Choice C implies a behavioral issue rather than a potential health risk.
Question 5 of 5
A client's wound is draining thick yellow material. The nurse correctly describes the drainage as:
Correct Answer: D
Rationale: The correct answer is D: Purulent. This is because thick yellow drainage indicates the presence of pus, which is characteristic of purulent drainage. Pus consists of dead white blood cells, tissue debris, and bacteria, signifying infection. Sanguineous drainage is fresh red blood, serous-sanguineous is a mix of clear and red drainage, and serous is clear and watery. Therefore, in this case, purulent is the most appropriate description of the drainage.