ATI RN
Introduction to Nursing Pdf Questions
Question 1 of 5
A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy?
Correct Answer: D
Rationale: The correct answer is D: Internal and superficial bleeding. Thrombolytic therapy works by breaking down blood clots, which can lead to bleeding as a side effect. This is the most common undesirable effect because it is directly related to the mechanism of action of thrombolytic agents. Dysrhythmias (choice A), although possible, are less common and not directly related to the drug's action. Nausea and vomiting (choice B) are general side effects that are not specific to thrombolytic therapy. Anaphylactic reactions (choice C) are rare but serious adverse effects that can occur with any medication, not just thrombolytics.
Question 2 of 5
Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction (MI)?
Correct Answer: B
Rationale: The correct answer is B: Ask about chest pain. This is because assessing the presence or absence of chest pain is a critical indicator of the effectiveness of IV nitroglycerin in managing myocardial infarction. Chest pain is a cardinal symptom of MI, and the relief or reduction of chest pain indicates that the nitroglycerin is working to improve blood flow to the heart muscle. Monitoring heart rate, checking blood pressure, and observing for dysrhythmias are important assessments in managing MI, but they do not directly reflect the effectiveness of nitroglycerin therapy.
Question 3 of 5
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take?
Correct Answer: D
Rationale: The correct answer is D because administering pain medication will help alleviate the client's discomfort, enabling them to take deep breaths essential for lung expansion following chest tube placement. Deep breathing prevents complications like atelectasis. Option A is incorrect as ambulation may be painful. Option B does not address the client's pain issue. Option C is wrong because shallow breaths can lead to lung complications.
Question 4 of 5
Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway?
Correct Answer: A
Rationale: The correct answer is A: Weak cough effort. A weak cough effort indicates ineffective airway clearance as coughing helps clear secretions and foreign particles from the airway. Profuse green sputum (B) indicates infection but not necessarily inability to clear the airway. Respiratory rate of 28 breaths/min (C) and low SpO2 (D) suggest respiratory distress but do not specifically indicate inability to clear the airway. Weak cough effort directly relates to the airway's ability to clear, making it the most specific finding.
Question 5 of 5
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that do not apply.)
Correct Answer: D
Rationale: The correct answer is D because fluorescent light bulbs can pose a fire hazard when used near oxygen due to their high energy output. Oxygen supports combustion, and fluorescent bulbs can generate heat and sparks. A, B, and C are incorrect because they are factors that the nurse should assess for safe oxygen use in the home. Smoking prohibition prevents fire risks, functional electrical cords prevent electrical hazards, and storing flammable liquids away from oxygen reduces the risk of explosions.