ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
A client who is scheduled for a bone marrow aspiration asks the nurse about the site that will be used for the procedure. The nurse tells the client that in addition to the iliac crest, the____ may be used.
Correct Answer: C
Rationale: The correct answer is C: Sternum. The sternum is another common site for bone marrow aspiration, along with the iliac crest. The sternum is easily accessible, especially in emergency situations. Aspiration from the sternum is less painful compared to the iliac crest. The femur (choice A) is not typically used for bone marrow aspiration due to the risk of injury to major blood vessels. The ribs (choice B) are not ideal due to the risk of pneumothorax. The scapula (choice D) is not commonly used due to limited accessibility and risk of injury to surrounding structures.
Question 2 of 5
A postoperative patient has ineffective airway clearance. Which data would indicate to the nurse that interventions for this patient problem have been successful?
Correct Answer: C
Rationale: The correct answer is C because clear breath sounds indicate effective airway clearance. Clear breath sounds suggest that air is flowing freely through the airways, indicating successful interventions. A: Fluid intake does not directly reflect airway clearance. B: Using a spirometer may improve lung function but does not necessarily indicate effective airway clearance. D: Temperature is not directly related to airway clearance.
Question 3 of 5
A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance?
Correct Answer: B
Rationale: The correct answer is B: Daily weight. Daily weight monitoring is the most accurate way to evaluate fluid balance in a patient with hypovolemia as it directly reflects changes in body fluid status. Weight changes are a sensitive indicator of fluid retention or loss. Skin turgor (A) is more indicative of dehydration rather than overall fluid balance. Urine output (C) is important but may not capture total fluid status. Edema presence (D) indicates fluid overload rather than hypovolemia.
Question 4 of 5
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
Correct Answer: A
Rationale: The correct answer is A: Lung sounds. When a patient receives a hypertonic solution like 3% NaCl for hyponatremia, there is a risk of fluid shifting from the intravascular space to the interstitial spaces, potentially causing pulmonary edema and respiratory distress. Monitoring lung sounds is crucial to detect any signs of fluid overload and intervene promptly. B: Urinary output is important but not as critical as monitoring lung sounds in this context. C: Peripheral pulses and D: Peripheral edema are not directly related to the potential complications of receiving a hypertonic solution like 3% NaCl.
Question 5 of 5
The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction?
Correct Answer: B
Rationale: The correct answer is B because using a heating pad on the feet can actually worsen PAD symptoms by dilating blood vessels and increasing blood flow, potentially leading to further ischemia. A: Choosing loose clothes helps improve circulation, as tight clothing can restrict blood flow. C: Walking to the point of pain and resting is a common exercise strategy for PAD patients. D: Changing positions frequently and avoiding prolonged sitting can prevent blood pooling and promote circulation.