ATI RN
Introduction to Nursing Quizlet Questions
Question 1 of 5
A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?
Correct Answer: C
Rationale: The correct nursing diagnosis of "Excessive fluid volume" takes highest priority for the client with chronic renal failure due to the presenting signs and symptoms of fluid overload: high blood pressure, neck vein distention, and bibasilar crackles indicating fluid in the lungs. Managing fluid volume is crucial to prevent complications such as pulmonary edema and worsening renal function. Fear (A) is not the priority as physiological needs should be addressed first. Urinary retention (B) is not the priority as the client's symptoms are more indicative of fluid overload rather than urinary retention. Self-care deficient: Toileting (D) is not the priority as it does not address the immediate physiological threat posed by excessive fluid volume.
Question 2 of 5
The nurse is about to obtain the temperature of a four-year-old child through the tympanic route. The nurse should:
Correct Answer: D
Rationale: The correct answer is D: Pull the pinna of the ear backwards and upwards. This direction allows for proper alignment of the ear canal with the tympanic membrane, ensuring accurate temperature measurement. Pulling the pinna backwards and upwards straightens the ear canal for better contact with the thermometer, leading to a more precise reading. Choices A, B, and C would not facilitate optimal alignment for accurate tympanic temperature measurement and could potentially result in an incorrect reading.
Question 3 of 5
A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate. A sudden change in the client's respiratory rate, especially if the client becomes profoundly short of breath, indicates a critical change in condition such as respiratory distress or failure. This is a priority assessment as it directly relates to the client's oxygenation and respiratory status. In this scenario, the client's increased respiratory rate of 26 breaths per minute, along with the symptoms of profound shortness of breath and gray skin color, indicates potential respiratory compromise. Monitoring the respiratory rate would have alerted the nurse first to the client's deteriorating condition. Summary of other choices: A: Heart rate - Although an elevated heart rate of 110 bpm is present, it is less indicative of respiratory distress compared to the respiratory rate in this situation. C: Blood pressure - The blood pressure of 120/70 is within normal range and may not be the first indicator of respiratory distress. D: Temperature - A temperature of 100.4 degrees Fahrenheit is slightly
Question 4 of 5
When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue:
Correct Answer: C
Rationale: The correct answer is C: Giving away valued personal items. This is a critical behavioral cue for suicide risk as it indicates a potential desire to say goodbye or tie up loose ends before attempting suicide. It is a warning sign that should be taken seriously and addressed promptly. Choices A, B, and D are not directly related to suicide risk assessment and do not specifically indicate imminent danger. Angry outbursts, fear of being alone, and experiencing a loss are important considerations in mental health but do not directly signal an immediate risk of suicide.
Question 5 of 5
When administering oxygen with a partial rebreather mask, which of the following observations is most important to report to the respiratory therapy departments?
Correct Answer: B
Rationale: The correct answer is B: The reservoir bag collapses during inspiration. This is important to report because it indicates inadequate oxygen delivery to the patient, potentially leading to hypoxemia. The reservoir bag should remain inflated to ensure a sufficient oxygen supply. A: Moisture accumulation inside the mask is common and not a cause for concern unless excessive. C: The mask covering the mouth and nose is expected and does not impact oxygen delivery. D: The strap being snug ensures a proper fit but does not directly impact oxygen delivery. In summary, choice B is the correct answer as it directly relates to the effectiveness of oxygen delivery, while the other choices are not as critical in this context.