ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. The client remaining free of signs and symptoms of phlebitis indicates that the I.V. site is not infected or inflamed, ensuring proper infusion. 2. Phlebitis can lead to complications such as infection and thrombosis if not managed promptly. 3. Monitoring for phlebitis is crucial to prevent further complications and ensure the client's safety. 4. Options A, C, and D do not directly address the expected outcome of maintaining the client free of phlebitis symptoms.
Question 2 of 5
In assessing oral temperature, how long should the nurse wait prior to reading the thermometer?
Correct Answer: C
Rationale: The correct answer is C (2-3 minutes). After placing the oral thermometer under the tongue, waiting for 2-3 minutes allows for an accurate reading of the oral temperature to be obtained. This timeframe ensures that the thermometer has enough time to accurately measure the body temperature. A (30 seconds) is too short for an accurate reading as it may not provide enough time for the thermometer to stabilize. B (1 full minute) is also not sufficient for an accurate reading. D (10 minutes) is too long and unnecessary, as it can lead to discomfort for the patient and does not improve the accuracy of the reading.
Question 3 of 5
What type of fever would the nurse document if the client had a wide range of temperature fluctuations over normal for a period of 24 hours?
Correct Answer: B
Rationale: The correct answer is B: Remittent fever. Remittent fever is characterized by wide temperature fluctuations over normal within a 24-hour period, without returning to normal in between. Intermittent fever has periods of normal temperature between spikes. Relapsing fever has recurring episodes of fevers with symptom-free intervals. Constant fever remains consistently elevated without fluctuations. Therefore, the correct choice is B as it aligns with the described temperature pattern.
Question 4 of 5
A 3 year-old child is brought to the clinic by his grandmother to be seen for scratching his bottom and wetting the bed at night." Based on these complaints
Correct Answer: D
Rationale: The correct answer is D: Regression. In this scenario, the child is showing behaviors such as scratching his bottom and bedwetting, which are common signs of regression in young children. Regression often occurs in response to stress or changes in the child's environment. By selecting this answer, the nurse can explore potential stressors in the child's life and provide appropriate support. A: Not the initial assessment as the symptoms are indicative of a psychological issue rather than a physical problem. B: Allergies are unlikely to cause both scratching bottom and bedwetting. C: Scabies may cause itching but is less likely to cause bedwetting.
Question 5 of 5
The nurse further asked the client to move her tongue side to side & up and down. The nurse is checking what cranial nerve with this process?
Correct Answer: B
Rationale: The correct answer is B: Glossopharyngeal nerve. Moving the tongue side to side & up and down tests the function of the glossopharyngeal nerve (cranial nerve IX), responsible for controlling the muscles of the tongue and throat. The other choices are incorrect because: A: Facial nerve (VII) controls facial expressions, not tongue movements. C: Trigeminal nerve (V) controls chewing and sensation in the face, not tongue movement. D: Abducens nerve (VI) controls eye movement, not tongue movements.