ATI RN
Chapter 1 Introduction to Nursing Quizlet Questions
Question 1 of 5
A client is admitted with frequent, loose stools. Prior to implementing orders to insert a Foley catheter, the nurse would first:
Correct Answer: A
Rationale: Step 1: Assess the client's condition and potential causes of frequent, loose stools. Step 2: Apply a fecal incontinence bag to contain and monitor stool output. Step 3: Monitor the effectiveness of the bag in managing stool output. Step 4: If necessary, implement further interventions based on assessment findings. Summary: - Option B: Performing perineal care is important for hygiene but does not directly address the issue of managing stool output. - Option C: Administering an antidiarrheal agent may mask symptoms without addressing the underlying cause. - Option D: Inserting a rectal tube is invasive and not typically indicated before trying less invasive interventions like a fecal incontinence bag.
Question 2 of 5
To prepare a patient for a paracentesis, it is essential for the nurse to:
Correct Answer: D
Rationale: Correct Answer: D - Have the patient empty his bladder Rationale: 1. Emptying the bladder prevents discomfort during the procedure. 2. A full bladder may increase the risk of injury during paracentesis. 3. It ensures accurate measurement of fluid output post-procedure. 4. Administering enema and restricting fluids are unnecessary and unrelated. 5. Pre-medicating with a narcotic analgesic is not routine practice for paracentesis.
Question 3 of 5
A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss?
Correct Answer: B
Rationale: The correct answer is B. Anxious clients with tachypnea are at greatest risk for insensible water loss due to increased respiratory rate leading to increased water evaporation from the lungs. This results in higher water loss compared to other options. Clients taking furosemide (A) may experience increased urine output but it is not considered insensible water loss. Clients on fluid restrictions (C) would have decreased water intake but it is not insensible loss. Constipated clients (D) may have fluid imbalance but it is not related to insensible water loss.
Question 4 of 5
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a band count of 11%. What prescribed action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Obtain cultures of the wound. With an elevated WBC count and high band count, there is a high suspicion of infection. Obtaining cultures will help identify the specific pathogen causing the infection and guide appropriate antibiotic therapy. This is crucial for effective treatment and preventing complications. Incorrect choices: B: Beginning antibiotic administration without knowing the specific pathogen may lead to inappropriate treatment. C: Continuing to monitor the wound for drainage does not address the underlying infection. D: Redressing the wound with wet-to-dry dressings does not address the need for identifying the specific pathogen causing the infection.
Question 5 of 5
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client’s teaching?
Correct Answer: B
Rationale: The correct answer is B: “Notify the clinic if you notice muscle twitching.” Muscle twitching can be a symptom of hyponatremia, which is a condition characterized by low sodium levels in the blood. The nurse should include this statement in the client’s teaching because it is important for the client to recognize and report this symptom promptly to prevent potential complications. Muscle twitching can indicate worsening hyponatremia and requires medical attention. Incorrect choices: A: “Have your spouse watch you for irritability and anxiety.” This choice focuses on emotional symptoms rather than physical symptoms of hyponatremia. C: “Call your primary health care provider for diarrhea.” Diarrhea is not a common symptom of hyponatremia; this choice is unrelated to the condition. D: “Bake or grill your meat rather than frying it.” This choice is unrelated to the prevention or management of hyponatremia.