ATI RN
Introduction to Nursing Quizlet Questions
Question 1 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 2 of 5
The nurse is administering a thrombolytic agent to a patient with an acute myocardial infarction. What patient data indicates that the nurse should stop the drug infusion?
Correct Answer: C
Rationale: The correct answer is C: Decreased level of consciousness. This indicates a potential complication such as intracranial bleeding, a serious adverse effect of thrombolytic therapy. Stopping the drug infusion is crucial to prevent further harm. Bleeding from the gums (A) is a common side effect of thrombolytic therapy but does not necessarily warrant stopping the infusion. An increase in blood pressure (B) may be expected due to the patient's condition and should be managed but does not indicate stopping the infusion. A nonsustained episode of ventricular tachycardia (D) may require treatment but does not mandate stopping the drug infusion unless it progresses to sustained ventricular tachycardia.
Question 3 of 5
The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
Correct Answer: A
Rationale: The correct answer is A because a low O2 saturation level of 88% indicates hypoxemia, which is a critical condition that requires immediate intervention to prevent further complications. Hypoxemia can occur after thoracentesis due to a pneumothorax or other respiratory issues. Choice B is not the priority because the blood pressure is slightly elevated but not immediately life-threatening. Choice C may indicate respiratory distress but is not as urgent as hypoxemia. Choice D is important for pain management but not as urgent as addressing hypoxemia. In summary, O2 saturation is the priority because hypoxemia can lead to serious complications if not promptly addressed.
Question 4 of 5
The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to 88% while ambulating. What is the priority action of the nurse?
Correct Answer: B
Rationale: The correct answer is B: Administer PRN supplemental O2. A decrease in SpO2 from 93% to 88% indicates hypoxemia during ambulation, requiring immediate intervention to improve oxygenation. Administering supplemental O2 is crucial to prevent further complications. Notifying the healthcare provider (A) can cause delays in addressing the hypoxemia. Documenting the response to exercise (C) is important but not the immediate priority. Encouraging the patient to pace activity (D) is not sufficient to address the acute hypoxemia.
Question 5 of 5
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
Correct Answer: B
Rationale: The correct answer is B: Blood cultures from two sites. This should be implemented first to identify the specific bacteria causing the infection and guide appropriate antibiotic therapy. Cultures help determine the most effective treatment and prevent antibiotic resistance. Chest x-ray (A) can wait as it does not provide immediate treatment. Administering antibiotics like Cipro (C) should be based on culture results. Acetaminophen (D) can help with fever but is not the priority in this case.