ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
A client with a chest tube attached to a Pleurevac drainage system wants to get out of bed. While the nurse is assisting the client, the chest tubing accidentally gets caught in the bed rail and disconnects and the Pleur-Evac drainage system falls over and cracks. The nurse takes which immediate action?
Correct Answer: C
Rationale: The correct immediate action is to immerse the chest tube in a bottle of sterile normal saline. This is because it helps to maintain the sterility of the system and prevents air from entering the pleural space, thus avoiding a potential pneumothorax. Clamping the chest tube (choice A) can lead to tension pneumothorax. Applying petroleum gauze over the end of the chest tube (choice B) does not address the issue of maintaining sterility or preventing air leaks. Calling the physician (choice D) is not the immediate action needed to address the disconnection and potential contamination of the chest tube system.
Question 2 of 5
During the physical examination, the nurse uses various techniques to assess structures, organs, and body systems. Which technique allows the nurse to feel for vibration and locate body structures?
Correct Answer: C
Rationale: The correct answer is C: Palpation. Palpation involves using hands to feel for vibration and locate body structures. This technique allows the nurse to assess for tenderness, texture, temperature, and size of organs or structures. Auscultation (A) involves listening for sounds using a stethoscope, not feeling. Inspection (B) involves visual examination, not tactile assessment. Percussion (D) involves tapping the body to listen for sounds, not feeling for vibration or locating structures. Palpation is the most appropriate technique for this purpose.
Question 3 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 4 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 5 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.