ATI RN
Basic Care of Patient Questions
Question 1 of 5
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
Correct Answer: A
Rationale: Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.
Question 2 of 5
The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory tests and allergies and prepares the patient for surgery. In which perioperative nursing phase is the nurse working?
Correct Answer: B
Rationale: The correct answer is B: Preoperative. In this phase, the nurse is completing assessments, reviewing lab tests, and preparing the patient for surgery. This phase occurs before the surgical procedure takes place. Perioperative (A) encompasses all phases of surgery, including preoperative, intraoperative (C), and postoperative (D). Intraoperative (C) refers to the phase during the actual surgical procedure. Postoperative (D) is the phase after surgery when the patient is in recovery. Therefore, B is the correct choice as it specifically relates to the actions the nurse is taking before the surgery.
Question 3 of 5
The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action will be most appropriate for this area?
Correct Answer: D
Rationale: The most appropriate nursing action in the preoperative holding area is to apply a warm blanket. This helps maintain the patient's body temperature, preventing hypothermia, which is common in surgical settings. It promotes patient comfort and relaxation, reducing anxiety. Counting sterile instruments (Choice A) is typically done by the surgical team. Emptying the urinary drainage bag (Choice B) is not necessary in the preoperative area. Checking the surgical dressing (Choice C) is more relevant postoperatively. Applying a warm blanket (Choice D) aligns with preoperative patient care guidelines.
Question 4 of 5
You are called to a scene for a 48-year-old male presenting with sudden onset of severe shortness of breath, tachypnea, and a rapid pulse. He is alert and oriented, and physical exam reveals a swollen right calf with tenderness. Which condition is most likely causing his symptoms?
Correct Answer: B
Rationale: The correct answer is B: Pulmonary embolism. Given the sudden onset of severe shortness of breath, tachypnea, rapid pulse, and swollen right calf with tenderness, the most likely diagnosis is a pulmonary embolism. A pulmonary embolism occurs when a blood clot travels to the lungs, blocking blood flow. This leads to symptoms of shortness of breath, tachypnea, and rapid pulse. The swollen right calf with tenderness suggests a possible deep vein thrombosis, which can lead to a pulmonary embolism. The other choices are less likely because they do not fully encompass the patient's presentation and physical exam findings. A myocardial infarction typically presents with chest pain, not solely shortness of breath and calf swelling. Tension pneumothorax presents with respiratory distress and decreased breath sounds, not calf swelling. Severe asthma attack may cause shortness of breath but is less likely to present with a swollen calf.
Question 5 of 5
When conducting a 12-lead electrocardiogram on a patient, which lead is located on the right side of the body and does not view a specific area of the heart?
Correct Answer: C
Rationale: The correct answer is C: aVR. Lead aVR is located on the right side of the body and does not view a specific area of the heart. In a 12-lead ECG, aVR is a unipolar lead that looks towards the right shoulder and does not provide a specific view of any particular area of the heart. This lead is mainly used as a reference point to help interpret the overall electrical activity of the heart. Leads V4, I, and aVL are all standard leads that view specific areas of the heart and are important for diagnosing cardiac conditions. Lead V4 views the anterior wall of the heart, Lead I views the lateral wall, and Lead aVL views the high lateral wall.