ATI RN
Introduction to Nursing Pdf Questions
Question 1 of 5
A nurse in the ICU is caring for a patient with PEEP. The patient suddenly called the nurse, and said: “Nurse, my leg is severely aching!” What is your priority nursing action?
Correct Answer: C
Rationale: The correct answer is C: Check the balloon of the ET tube. This is the priority nursing action because PEEP (Positive End-Expiratory Pressure) is a mechanical ventilation setting that can lead to accidental migration of the endotracheal (ET) tube, causing pressure on surrounding structures like the vocal cords or trachea, leading to referred pain in the leg. Checking the balloon of the ET tube ensures proper placement and prevents complications. Choice A: Checking the condition of the leg is not the priority as the patient's complaint is likely related to the mechanical ventilation. Choice B: Checking for pain scale is not the priority as addressing the source of the pain is more critical. Choice D: Giving analgesic is not appropriate until the cause of the leg pain is identified.
Question 2 of 5
The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal?
Correct Answer: B
Rationale: The correct answer is B: Urine pH of 3.0 is abnormal. Normal urine pH ranges from 4.6 to 8.0. A pH of 3.0 indicates highly acidic urine, which may be indicative of certain health conditions. Specific gravity of 1.03 is within the normal range (1.005-1.030). Absence of protein and glucose in urine is normal. Proteinuria and glucosuria are typically abnormal findings.
Question 3 of 5
When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing?
Correct Answer: B
Rationale: The correct answer is B because oral hypoglycemic agents are important in managing blood sugar levels. High blood sugar can impair wound healing and increase the risk of infection. Controlling blood sugar levels is crucial for optimal wound healing. A: The duration of injury does not directly impact wound healing compared to managing underlying conditions. C: Pain management is important but does not directly affect wound healing. D: Keloids are unrelated to pressure injuries and do not impact wound healing.
Question 4 of 5
The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?
Correct Answer: A
Rationale: The correct answer is A: Administer high-ceiling (loop) diuretics. In fluid overload, loop diuretics help the body eliminate excess fluid rapidly, which is a priority intervention. Assessing lung sounds (B) is important but not as urgent as addressing the fluid overload. Placing a pressure-relieving overlay (C) is not directly related to managing fluid overload. Weighing the client daily (D) is important for monitoring fluid status but does not address the immediate need for fluid removal.
Question 5 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.