ATI RN
Introduction to Nursing Quizlet Questions
Question 1 of 5
A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?
Correct Answer: B
Rationale: The correct answer is B: Increase your fluid intake to 2 to 3 L per day. This instruction is important after extracorporeal shock wave lithotripsy to help flush out the stone fragments and prevent urinary tract infections. Increasing fluid intake also helps prevent dehydration and promotes kidney function. A: Taking temperature every 4 hours is not necessary post-lithotripsy unless the client develops signs of infection. C: Applying an antibacterial dressing daily is not typically required after lithotripsy unless specifically instructed by the healthcare provider. D: Urine turning cherry red after lithotripsy is due to blood in the urine, which is expected, but this should resolve within 24-48 hours, not 5 to 7 days.
Question 2 of 5
A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first?
Correct Answer: D
Rationale: The correct answer is D because assessing the right leg for pulses, skin color, and temperature is the priority to determine the perfusion status and tissue viability. This step is crucial in identifying any vascular compromise that could be contributing to the nonhealing pressure injury. Drawing blood for albumin, prealbumin, and total protein (A) can provide information on the client's nutritional status but is not the immediate priority. Preparing for a wound culture (B) is important for determining the presence of infection but should come after assessing perfusion. Instructing the client to elevate the foot (C) can help with reducing edema but is not the first action when dealing with a nonhealing pressure injury.
Question 3 of 5
A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?
Correct Answer: D
Rationale: The correct answer is D because the use of multiple herbs and supplements can interact with anesthesia and other medications during surgery, potentially causing adverse effects. It is crucial for the surgical team to be aware of this information to ensure the client's safety. A: Allergy to bee and wasp stings - Although allergies are important, this information may not directly impact the surgical procedure and can be managed with standard protocols. B: History of lactose intolerance - Lactose intolerance typically does not have a significant impact on surgery unless specific dietary restrictions are necessary, which can be easily managed. C: No previous experience with surgery - While this information is relevant for emotional support, it does not directly affect the surgical procedure itself.
Question 4 of 5
A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select the one that does not apply..)
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Fluid overload typically presents with increased pulse rate (A) due to increased blood volume, distended neck veins (B) from increased venous pressure, and warm and pink skin (D) due to increased cardiac output. However, decreased blood pressure (C) is not a common sign of fluid overload as the body compensates by maintaining or even increasing blood pressure to accommodate the excess fluid.
Question 5 of 5
The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first?
Correct Answer: A
Rationale: The correct answer is A: Obtain vital signs. This is the first action the nurse should perform because it helps assess the patient's immediate status post-procedure. Vital signs can indicate any complications or changes in the patient's condition that may require immediate intervention. Assessing vital signs is crucial in monitoring the patient's stability and response to the procedure. Summary: - B: Teaching wound care can be important but is not the priority immediately post-procedure. - C: Assessing pedal pulses is important but obtaining vital signs takes precedence to assess the overall status. - D: Checking the wound site is important, but vital signs should be assessed first to ensure the patient's immediate well-being.