ATI RN
Introduction to Nursing Questions
Question 1 of 5
A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound?
Correct Answer: D
Rationale: The correct answer is D: Multi-fiber superabsorbent dressing. This type of dressing is ideal for a wound with copious exudate as it can effectively absorb and contain the excessive fluid. It helps maintain a moist wound environment conducive to healing while preventing maceration. Wet-to-damp gauze (A) can cause trauma upon removal. Leaving the wound open (B) increases the risk of infection. Transparent film (C) may not provide enough absorbency for a wound with high exudate.
Question 2 of 5
A patient with aortic stenosis has acute pain due to decreased coronary blood flow. What would be an appropriate nursing intervention for this patient?
Correct Answer: A
Rationale: Correct Answer: A: Promote rest to decrease myocardial oxygen demand. Rationale: 1. Aortic stenosis leads to decreased coronary blood flow, causing myocardial ischemia and pain. 2. Rest decreases myocardial oxygen demand, reducing the workload on the heart. 3. By promoting rest, the body's oxygen demand decreases, helping to alleviate the acute pain. 4. Teaching about anticoagulant therapy (B) and nitroglycerin use (C) are not directly related to addressing decreased coronary blood flow. 5. Raising the head of the bed (D) to decrease venous return would not directly address the underlying issue of decreased coronary blood flow and acute pain.
Question 3 of 5
The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data should be of most concern to the nurse?
Correct Answer: B
Rationale: The correct answer is B: Blood pressure is 90/40 mm Hg. This is the most concerning assessment data because it indicates hypotension, which can be a sign of hypovolemic shock in a patient with massive burn injury. Hypotension can lead to inadequate tissue perfusion and organ failure. Choice A is not as concerning as low urine output can be expected in a hypovolemic patient. Choice C is not as critical as oral fluid intake may vary, but IV fluids can be administered if needed. Choice D, skin tenting, is a sign of dehydration but is not as immediately life-threatening as hypotension.
Question 4 of 5
A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first?
Correct Answer: D
Rationale: The correct answer is D. The nurse should assess the 27-year-old client with a heart rate of 120 beats/min first as an elevated heart rate can indicate respiratory distress or other serious underlying conditions. This assessment is crucial for immediate intervention. A: A 66-year-old client with a barrel chest and clubbed fingernails may indicate chronic obstructive pulmonary disease but does not require immediate attention compared to a high heart rate. B: A 48-year-old client with an oxygen saturation level of 92% at rest indicates potential hypoxemia but does not pose an immediate threat as the client is at rest. C: A 35-year-old client reporting orthopnea indicates difficulty breathing when lying flat, which is concerning but less urgent compared to a high heart rate.
Question 5 of 5
Which information will be most important for the nurse to communicate to the health care provider about an older patient who has influenza?
Correct Answer: B
Rationale: The correct answer is B: Diffuse crackles in the lungs. This is the most important information to communicate because it indicates a potential complication like pneumonia in older patients with influenza. Crackles suggest fluid accumulation in the lungs, requiring prompt medical attention. Fever (A) and myalgia/headache (D) are common symptoms of influenza but may not indicate severe complications. Sore throat and cough (C) are typical symptoms and do not directly point to a serious issue like lung involvement.