ATI RN
Introduction to Nursing Questions
Question 1 of 5
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
Correct Answer: B
Rationale: The correct answer is B: Ensure that informed consent is on the chart. This is the priority because obtaining informed consent is a legal and ethical requirement before any invasive procedure. It ensures the client understands the procedure, risks, benefits, and alternatives. Administering anxiolytic medication can help with anxiety but is not the priority. Reinforcing teaching and starting preoperative antibiotics are important but come after ensuring informed consent to prioritize the client's autonomy and safety.
Question 2 of 5
While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate?
Correct Answer: C
Rationale: The correct answer is C: Increased right atrial pressure. Jugular venous distention (JVD) with the head of the bed elevated indicates increased pressure in the right atrium, leading to backflow and distention of the jugular veins. This is commonly seen in conditions like heart failure or fluid overload. Incorrect choices: A: Decreased fluid volume - This is incorrect because JVD is typically associated with volume overload, not decreased fluid volume. B: Jugular vein atherosclerosis - This is incorrect as atherosclerosis is a condition of the arteries, not the veins. D: Incompetent jugular vein valves - This is incorrect as incompetent valves may lead to venous reflux but are not directly related to JVD seen in this scenario.
Question 3 of 5
The nurse is assessing the client who presented to the emergency department with a serum sodium level of 114 mEg/L. Which findings would the nurse relate to the serum sodium level? Select all that do not apply.
Correct Answer: D
Rationale: The correct answer is D: Warm, flushed skin. A serum sodium level of 114 mEg/L indicates hyponatremia. Hyponatremia causes water to move into cells, leading to cellular swelling and potential neurological symptoms. Muscle weakness, headache, and confusion are all associated with hyponatremia due to neurological effects. However, warm, flushed skin is not typically related to hyponatremia; instead, it may be seen in conditions like hyperthermia or vasodilation. Therefore, the nurse would not relate warm, flushed skin to the low serum sodium level in this case.
Question 4 of 5
A patient has administered regular insulin 30 minutes prior but has not received a breakfast tray. The patient is experiencing nervousness and tremors. What is the nurse's first action?
Correct Answer: D
Rationale: The correct answer is D: Perform bedside glucose testing. The patient is likely experiencing hypoglycemia due to insulin administration without food intake. Performing bedside glucose testing will confirm hypoglycemia and guide appropriate interventions. Administering glucagon (choice A) is not the first-line action for mild hypoglycemia. Giving orange juice (choice B) could be considered, but confirming hypoglycemia first is crucial. Notifying the kitchen to deliver the tray (choice C) delays immediate assessment and intervention.
Question 5 of 5
The nurse is performing an assessment on a patient who will begin taking propranolol (Inderal) to treat hypertension. The nurse learns that the patient has a history of asthma and diabetes. The nurse will take which action?
Correct Answer: B
Rationale: Step 1: Identify contraindications - Propranolol is contraindicated in patients with asthma due to its potential to exacerbate bronchospasm. Step 2: Recognize patient history - The patient has a history of asthma. Step 3: Assess for comorbidities - The patient also has diabetes, which is another consideration in selecting appropriate antihypertensive medication. Step 4: Consider safer alternatives - Given the contraindications and comorbidities, contacting the provider to discuss an alternative antihypertensive medication is the best course of action. Step 5: Monitor for adverse effects - Administering the medication without addressing the contraindications could lead to serious complications. Summary: Option B is correct as it addresses the contraindications and comorbidities, ensuring patient safety. Options A, C, and D are incorrect as they do not address the potential risks associated with propranolol in this specific