ATI RN
Introduction to Nursing Chapter 1 Quizlet Questions
Question 1 of 5
A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client?
Correct Answer: C
Rationale: The correct answer is C: Deficient fluid volume related to nausea and vomiting. Priority is given to addressing fluid volume deficits to prevent dehydration and electrolyte imbalances. Nausea, vomiting, and fever can lead to significant fluid loss. Choice A is incorrect as excessive fluid volume is not indicated. Choice B is incorrect as addressing nutrition would come after addressing fluid volume. Choice D is incorrect as hyperventilation does not typically lead to ineffective cardiopulmonary tissue perfusion in this scenario.
Question 2 of 5
A 60-year old client reports to the nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blister like lesions that are filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?
Correct Answer: D
Rationale: The correct answer is D: Vesicles. Vesicles are small, elevated lesions filled with clear fluid, typically less than 0.5 cm in diameter. In this case, the client's presentation of elevated, round, blister-like lesions filled with clear fluid matches the description of vesicles. Pustules (A) are similar in appearance but contain pus, while papules (B) are raised, solid lesions without fluid-filled cavities. Plaques (C) are flat, raised lesions typically larger than 1 cm in diameter. Therefore, based on the specific characteristics of the lesions described in the scenario, the appropriate term to use would be vesicles.
Question 3 of 5
All of the following are correct methods in the assessment of blood pressure except:
Correct Answer: D
Rationale: The correct answer is D because pumping the cuff to around 50 mmHg above the point where the pulse is obliterated is incorrect. The correct method is to pump the cuff to about 30 mmHg above the point where the pulse disappears. Pumping too high can lead to inaccurate readings. Observing procedures for infection control (A), taking BP on both arms for comparison (B), and listening to identify Korotkoff sounds (C) are all correct methods in the assessment of blood pressure, ensuring accuracy and reliability.
Question 4 of 5
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
Correct Answer: A
Rationale: The correct answer is A: A 79 year-old malnourished client on bed rest. This client is at highest risk for decubitus ulcers due to malnourishment causing poor tissue healing, and immobility leading to pressure ulcers. The other choices are less likely: B may have increased pressure but obesity does not directly correlate with ulcer risk, C's incontinence may increase risk of skin breakdown but not as high as malnutrition and immobility, and D's ambulatory status reduces the risk compared to bed rest.
Question 5 of 5
After a lumbar puncture, the nurse should place the client in:
Correct Answer: A
Rationale: The correct answer is A: Supine position with a pillow. Placing the client in a supine position with a pillow helps prevent post-lumbar puncture headache by aiding in the restoration of normal cerebrospinal fluid pressure. The pillow supports the head and neck, reducing strain on the puncture site. Choice B: Supine with neck hyperextended is incorrect as it can increase the risk of complications and discomfort for the client. Choice C: Prone for 24 hours is incorrect as it can lead to increased pressure on the puncture site and hinder the recovery process. Choice D: Orthopneic is incorrect as this position is typically used for respiratory distress and not indicated post-lumbar puncture.