ATI RN
Introduction to Nursing Pdf Questions
Question 1 of 5
A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?
Correct Answer: C
Rationale: The correct answer is C, the 76-year-old who is cognitively impaired, is at the greatest risk for dehydration. Cognitive impairment can impact one's ability to recognize thirst cues or communicate their need for fluids. This client may forget to drink water or be unable to express their thirst, leading to dehydration. The other choices are less likely at risk for dehydration because: A) Long-term steroid therapy can increase thirst and fluid intake, B) Recent IV fluids indicate recent hydration, D) Congestive heart failure may lead to fluid retention rather than dehydration.
Question 2 of 5
What finding should the nurse expect during the assessment of a young adult with infective endocarditis (IE)?
Correct Answer: B
Rationale: The correct answer is B: A new regurgitant murmur. In infective endocarditis, vegetation on heart valves can cause valve dysfunction, leading to new regurgitant murmurs. This is a classic finding in IE assessment. Substernal chest pressure (A) is more common in conditions like angina or myocardial infarction. Pruritic rash on the chest (C) is not typically associated with IE. Involuntary muscle movement (D) is not a common finding in IE and is more suggestive of neurological conditions.
Question 3 of 5
Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction (MI)?
Correct Answer: B
Rationale: The correct answer is B: Ask about chest pain. This is because assessing the presence or absence of chest pain is a critical indicator of the effectiveness of IV nitroglycerin in managing myocardial infarction. Chest pain is a cardinal symptom of MI, and the relief or reduction of chest pain indicates that the nitroglycerin is working to improve blood flow to the heart muscle. Monitoring heart rate, checking blood pressure, and observing for dysrhythmias are important assessments in managing MI, but they do not directly reflect the effectiveness of nitroglycerin therapy.
Question 4 of 5
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take?
Correct Answer: D
Rationale: The correct answer is D because administering pain medication will help alleviate the client's discomfort, enabling them to take deep breaths essential for lung expansion following chest tube placement. Deep breathing prevents complications like atelectasis. Option A is incorrect as ambulation may be painful. Option B does not address the client's pain issue. Option C is wrong because shallow breaths can lead to lung complications.
Question 5 of 5
Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway?
Correct Answer: A
Rationale: The correct answer is A: Weak cough effort. A weak cough effort indicates ineffective airway clearance as coughing helps clear secretions and foreign particles from the airway. Profuse green sputum (B) indicates infection but not necessarily inability to clear the airway. Respiratory rate of 28 breaths/min (C) and low SpO2 (D) suggest respiratory distress but do not specifically indicate inability to clear the airway. Weak cough effort directly relates to the airway's ability to clear, making it the most specific finding.