ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?
Correct Answer: A
Rationale: The correct answer is A: Elevate the ankle above heart level. This action helps reduce swelling by promoting venous return and decreasing edema. Elevating the ankle aids in reducing inflammation and pain. Applying a warm moist pack (option B) may increase swelling and should be avoided initially. Asking the patient to bear weight (option C) could worsen the injury. Assessing passive ROM (option D) is important but should be done after elevating the ankle to address swelling first.
Question 2 of 5
A patient who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive which antidote?
Correct Answer: B
Rationale: The correct antidote for a patient who has taken too much warfarin is Vitamin K. Warfarin inhibits Vitamin K-dependent clotting factors, leading to bleeding. Vitamin K helps restore these clotting factors. Vitamin E does not reverse warfarin's effects. Protamine sulfate is an antidote for heparin, not warfarin. Potassium chloride is used for treating low potassium levels, not warfarin toxicity. In summary, Vitamin K is the correct antidote for warfarin toxicity due to its role in restoring Vitamin K-dependent clotting factors, while the other choices are not indicated for this specific situation.
Question 3 of 5
While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient’s bed elevated 45 degrees. What does this finding indicate?
Correct Answer: C
Rationale: Step 1: Jugular venous distention (JVD) is often indicative of increased pressure in the right atrium. Step 2: Elevating the head of the bed to 45 degrees helps accentuate JVD, making it easier to observe. Step 3: Increased right atrial pressure can be caused by conditions like heart failure or tricuspid valve regurgitation. Step 4: This finding is significant in older adults as they are more prone to cardiovascular issues. Summary: Choice A is incorrect as JVD typically indicates fluid overload, not decreased volume. Choice B is incorrect as atherosclerosis affects arteries, not veins. Choice D is incorrect as incompetent jugular vein valves would lead to backflow, not distention.
Question 4 of 5
An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram?(Select the one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A. Hypertension alone may not directly warrant an electrocardiogram (ECG) as it primarily indicates high blood pressure. However, fatigue despite adequate rest, indigestion, and abdominal pain can be symptoms of underlying cardiac issues that require an ECG for further evaluation. Fatigue can be a sign of heart problems affecting oxygen delivery, while indigestion and abdominal pain can be symptoms of a heart attack or other cardiac conditions. Requesting an ECG based on these symptoms can help identify potential cardiac issues early on.
Question 5 of 5
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that do not apply.)
Correct Answer: A
Rationale: Step-by-step rationale: 1. Chest x-ray is not routinely scheduled annually for monitoring complications in type 2 diabetes. 2. Blood pressure monitoring is essential for assessing cardiovascular risk in diabetic patients. 3. Serum creatinine levels are checked annually to assess kidney function. 4. Urine for microalbuminuria is done annually to detect early signs of kidney damage. 5. Since chest x-ray is not directly related to diabetes complications, it is the correct answer. Summary: A is correct because chest x-ray is not a standard test for monitoring type 2 diabetes complications. B, C, and D are incorrect as they are essential for evaluating cardiovascular risk, kidney function, and early signs of kidney damage in diabetic patients.