ATI RN
Introduction to Professional Nursing Questions
Question 1 of 5
A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best?
Correct Answer: C
Rationale: The correct answer is C: Increase the IV flow rate to 250 mL/hr. Dehydration-induced confusion requires prompt correction of fluid deficit. Increasing IV flow rate will help rehydrate the client more quickly, addressing the underlying cause of confusion. This intervention is directly related to resolving dehydration. A: Measuring intake and output every 4 hours is important for monitoring fluid balance but will not address dehydration promptly. B: Assessing the client further for fall risk is important but does not directly address the underlying cause of confusion. D: Placing the client in a high-Fowler position can help with respiratory issues but does not directly address dehydration-induced confusion.
Question 2 of 5
The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?
Correct Answer: B
Rationale: The correct answer is B: Fine crackles audible at both lung bases. This finding is most important to report because it suggests potential respiratory complications like atelectasis or pneumonia, which are common postoperative issues. The nurse should report this immediately to prevent further respiratory deterioration. A: Tympanic temperature of 99.2°F is slightly elevated but not a critical finding postoperatively. C: Redness and swelling along the suture line are common signs of surgical healing and expected in the early postoperative period. D: 200 mL sanguineous fluid in the wound drain is within the expected range for the second postoperative day after abdominal surgery and does not indicate an immediate concern.
Question 3 of 5
A patient is receiving heparin therapy as part of the treatment for a pulmonary embolism. The nurse monitors the results of which laboratory test to check the drug‘s effectiveness?
Correct Answer: B
Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor heparin therapy as it measures the effectiveness of the drug in prolonging clotting time. By monitoring aPTT levels, the nurse can ensure that the patient is within the therapeutic range to prevent clot formation without increasing the risk of bleeding. A: Bleeding times do not specifically monitor the effectiveness of heparin therapy and can be affected by various factors. C: Prothrombin time/international normalized ratio (PT/INR) is used to monitor warfarin therapy, not heparin. D: Vitamin K levels are not directly related to heparin therapy and are more relevant in monitoring patients on warfarin therapy.
Question 4 of 5
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Which instruction should the nurse include?
Correct Answer: C
Rationale: The correct answer is C: Notify the health care provider if nausea develops. This is important because nausea can be a sign of digoxin toxicity, a potential side effect of digoxin. By promptly notifying the healthcare provider, appropriate action can be taken to prevent any serious complications. A: Limit dietary sources of potassium - This is not directly related to the medications prescribed and is not necessary for the patient's current condition. B: Take the hydrochlorothiazide at bedtime - Timing of hydrochlorothiazide administration is not as critical as monitoring for side effects or interactions with other medications. D: Take the digoxin if the pulse is below 60 beats/min - This instruction could lead to potential overdosing if the patient takes digoxin unnecessarily based solely on heart rate without considering other factors.
Question 5 of 5
The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?
Correct Answer: D
Rationale: The correct answer is D: "Have you had dental work done recently?" This question helps identify a risk factor for infective endocarditis (IE) as dental procedures can introduce bacteria into the bloodstream, potentially leading to IE in individuals with prosthetic heart valves. Dental work is a known risk factor for IE due to the transient bacteremia that can occur during dental procedures, especially in those with prosthetic heart valves. Choices A, B, and C are incorrect as they do not directly relate to the risk factors for IE in this specific scenario. Asking about a history of heart attack (A) is not directly related to IE risk factors. Family history of endocarditis (B) may have some relevance, but it is not as directly linked to the current situation as dental work. Recent immunizations (C) are important for overall health but not a specific risk factor for IE in this case.