ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
Correct Answer: D
Rationale: The correct answer is D, Ineffective peripheral tissue perfusion related to venous congestion. Priority should be given to this nursing diagnosis because deep vein thrombosis can lead to impaired blood flow, potentially causing tissue ischemia and necrosis. Addressing ineffective tissue perfusion is crucial to prevent further complications such as tissue damage or even loss. Option A is incorrect as gas exchange is not the immediate concern in deep vein thrombosis. Option B is not directly related to the primary issue of venous congestion. Option C, risk for injury related to edema, is important but not as critical as ensuring adequate tissue perfusion to prevent further complications.
Question 2 of 5
Through the client’s history, you gather that the patient smokes and drinks coffee. When taking the temperature of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s oral temperature for accurate reading?
Correct Answer: C
Rationale: The correct answer is C: 30 minutes. After smoking or drinking coffee, the client's oral temperature can be affected by the hot or cold temperature of the substances ingested. Waiting for 30 minutes allows the client's oral cavity to return to its normal temperature, ensuring an accurate reading. Choices A, B, and D are incorrect because: A: 5 minutes is too short of a time for the oral cavity to adjust to the temperature changes caused by smoking or drinking coffee. B: 15 minutes may not be sufficient for the oral cavity to stabilize, leading to a potential inaccurate reading. D: 1 hour is too long of a wait time as the oral cavity typically stabilizes within 30 minutes after smoking or drinking coffee.
Question 3 of 5
While the client has a pulse oximeter on his fingertip, the nurse notices that sunlight is shining on the area of the sensor. The nurse’s action should be:
Correct Answer: C
Rationale: The correct answer is C: Cover the fingertip sensor with a towel or bedsheet. Sunlight shining on the sensor can interfere with accurate readings. By covering the sensor, the nurse eliminates the external light source and ensures correct measurements. Choice A is incorrect because sunlight can affect the accuracy of the pulse oximeter readings. Choice B is incorrect because changing the sensor location every 4 hours does not address the immediate issue of sunlight interference. Choice D is incorrect as setting the alarm does not solve the problem of sunlight affecting the sensor's accuracy.
Question 4 of 5
In performing enemas, the indicated height for adults should be:
Correct Answer: D
Rationale: The correct answer is D: 12-18 inches above the rectum. This height range ensures proper flow of the enema solution through gravity. If the enema bag is positioned too low (A), gravity may not assist in the flow. Placing it 10-16 inches above the bed (B) is not specific to the rectum. Option C (12-18 inches above the bed) does not guarantee proper flow into the rectum. Therefore, option D is the most appropriate height range for successful administration of the enema solution.
Question 5 of 5
If a client has been suctioned, how long should the nurse wait before drawing an arterial blood gas?
Correct Answer: D
Rationale: The correct answer is D (20 minutes) because after suctioning, it takes time for the respiratory system to stabilize and for arterial blood gas values to return to baseline. Waiting 20 minutes allows for accurate assessment of respiratory status. Choice A (5 minutes) is too soon and may lead to skewed results due to immediate changes post-suctioning. Choice B (10 minutes) is still too early for accurate results. Choice C (15 minutes) is closer but may not provide sufficient time for full recovery post-suctioning. Therefore, waiting for 20 minutes ensures more reliable arterial blood gas values.