ATI RN
Introduction to Nursing Quizlet Questions
Question 1 of 5
A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first?
Correct Answer: D
Rationale: The correct answer is D because assessing the right leg for pulses, skin color, and temperature is the priority to determine the perfusion status and tissue viability. This step is crucial in identifying any vascular compromise that could be contributing to the nonhealing pressure injury. Drawing blood for albumin, prealbumin, and total protein (A) can provide information on the client's nutritional status but is not the immediate priority. Preparing for a wound culture (B) is important for determining the presence of infection but should come after assessing perfusion. Instructing the client to elevate the foot (C) can help with reducing edema but is not the first action when dealing with a nonhealing pressure injury.
Question 2 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 3 of 5
The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first?
Correct Answer: A
Rationale: The correct answer is A: Obtain vital signs. This is the first action the nurse should perform because it helps assess the patient's immediate status post-procedure. Vital signs can indicate any complications or changes in the patient's condition that may require immediate intervention. Assessing vital signs is crucial in monitoring the patient's stability and response to the procedure. Summary: - B: Teaching wound care can be important but is not the priority immediately post-procedure. - C: Assessing pedal pulses is important but obtaining vital signs takes precedence to assess the overall status. - D: Checking the wound site is important, but vital signs should be assessed first to ensure the patient's immediate well-being.
Question 4 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 5 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.