ATI RN
Introduction to Professional Nursing Quizlet Questions
Question 1 of 5
A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury?
Correct Answer: C
Rationale: The correct answer is C: Stage 3. A stage 3 pressure injury involves full-thickness skin loss with damage or necrosis of subcutaneous tissue, but not extending to muscle or bone. In this case, the base of the wound involves subcutaneous tissue, indicating a stage 3 injury. Choice A (Stage 1) is incorrect as it involves non-blanchable erythema. Choice B (Stage 2) is incorrect as it involves partial-thickness skin loss with exposed dermis. Choice D (Stage 4) is incorrect as it involves full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.
Question 2 of 5
A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?
Correct Answer: C
Rationale: The correct answer is C: Potassium: 2.9 mEq/L (2.9 mmol/L). A potassium level of 2.9 mEq/L is critically low (normal range is 3.5-5.0 mEq/L) and can lead to life-threatening cardiac arrhythmias. Immediate communication with the surgical team is necessary to address this abnormality before surgery. Explanation of other choices: A: Creatinine level of 1.2 mg/dL is within normal range (0.6-1.3 mg/dL), not requiring immediate communication. B: Hemoglobin level of 14.8 mg/dL is also within normal range for males (13.8-17.2 mg/dL) and females (12.1-15.1 mg/dL), not warranting immediate communication. D: Sodium level of 134 mEq/L is within the normal range (135-145 mEq/L), so immediate communication is
Question 3 of 5
The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Avoid giving IM medications to prevent localized bleeding. When a patient is on heparin therapy with PTT monitoring, it is crucial to avoid IM injections to prevent localized bleeding due to the anticoagulant effects of heparin. IM injections can lead to hematomas and increased bleeding risk. Monitoring for bilateral pedal pulses (A) is important for assessing circulation but not directly related to heparin therapy. Decreasing the infusion when PTT is 65 seconds (B) is not appropriate as the therapeutic range for PTT varies depending on the patient's condition. Having vitamin K available (D) is not necessary for heparin reversal as vitamin K does not reverse the effects of heparin.
Question 4 of 5
Heparin is ordered for a patient with a non–ST-segment- elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient?
Correct Answer: C
Rationale: Step 1: Heparin is an anticoagulant medication that works by preventing the formation of new blood clots. Step 2: In NSTEMI, there is a risk of developing new clots in the coronary arteries, which can worsen the condition. Step 3: By explaining that heparin prevents the development of new clots, the nurse helps the patient understand the purpose of the medication in preventing further complications. Step 4: Option C is correct as it directly addresses the mechanism of action of heparin in NSTEMI. Step 5: Incorrect choices: A: Incorrect, as heparin does not enhance platelet aggregation but rather inhibits clot formation. B: Incorrect, as heparin does not decrease the size of coronary artery plaque. D: Incorrect, as heparin does not dissolve existing clots but prevents new clot formation.
Question 5 of 5
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?
Correct Answer: C
Rationale: The correct action is to medicate the patient with prescribed morphine first. The patient is experiencing incisional pain, poor cough effort, and coarse crackles, indicating possible atelectasis or pneumonia post-thoracotomy. Morphine will help relieve the pain, improve cough effort, and decrease anxiety associated with breathing difficulties. It is essential to address pain and discomfort to facilitate effective coughing and deep breathing exercises, promoting optimal lung expansion and preventing respiratory complications. Sitting upright, splinting the chest, or using the incentive spirometer are important interventions but addressing the pain is the priority in this situation.