ATI RN
Introduction to Professional Nursing Questions
Question 1 of 5
A nurse is caring for a client with a chest tube attached to a Pleurevac drainage system. Which of the following actions should the nurse avoid to prevent a tension pneumothorax?
Correct Answer: A
Rationale: Correct Answer: A: Clamping the chest tube Rationale: Clamping the chest tube can lead to a tension pneumothorax by preventing air from escaping the pleural space. This can cause a buildup of pressure, leading to lung collapse and potential life-threatening complications. Summary of other choices: B: Taping the connection can prevent air leaks and maintain the system's integrity. C: Adding water to the suction chamber is necessary to maintain suction and prevent air leaks. D: Maintaining the collection chamber below the client's waist helps with proper drainage and prevents backflow of fluid.
Question 2 of 5
A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing?
Correct Answer: B
Rationale: The correct answer is B: Assessment. In this scenario, the nurse is collecting data by obtaining the health history, measuring vital signs, and auscultating for bowel sounds. Assessment is the first step in the nursing process, where data is gathered to identify the client's health status. Planning (A) involves setting goals and outcomes, Evaluation (C) involves determining the effectiveness of interventions, and Implementation (D) involves carrying out the planned interventions. In this case, the nurse is still in the data collection phase, making Assessment the correct choice.
Question 3 of 5
The nurse is performing a breast assessment to a client. Which of the following findings is a deviation from normal?
Correct Answer: C
Rationale: The correct answer is C: Retraction or dimpling. This finding is a deviation from normal as it can indicate possible breast cancer or other abnormalities. Retraction or dimpling can be a sign of tissue distortion or fibrosis, which should be further evaluated. Presence of striae (A) is common and not a cause for concern. Breasts that are rounded (B) and slightly unequal in size are considered normal variations. Simply being round (D) does not necessarily indicate a deviation from normal.
Question 4 of 5
The nurse attached a pulse oximeter to a client. She knows that the purpose of this is to:
Correct Answer: C
Rationale: Rationale: Choice C is correct because a pulse oximeter measures oxygen saturation in arterial blood, providing crucial information on the client's oxygen levels. This helps monitor respiratory status and determine the need for supplemental oxygen. Choice A is incorrect as tissue perfusion is not directly assessed by a pulse oximeter. Choice B is incorrect as it measures hemoglobin indirectly. Choice D is incorrect as anti-hypertensive medications do not impact oxygen saturation directly.
Question 5 of 5
Which of these children at the site of a disaster at a child day care center would the triage nurse put in the treat last" category?"
Correct Answer: B
Rationale: The correct answer is B because the toddler with severe deep abrasions over 98% of the body would be categorized as "treat last" in triage. This decision is based on the principle of prioritizing care based on the severity of injuries. Severe deep abrasions over a large body surface area indicate a critical condition that requires immediate medical attention to prevent complications like infection or shock. The other choices do not present as immediate life-threatening conditions as the severe abrasions, hence they would not be categorized as "treat last." The infant with bulging anterior fontanel may have a concerning sign, but it does not indicate an immediate life-threatening condition. The preschooler with leg fractures and school-age child with singed hair also do not present as critical as the toddler with severe abrasions.