ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
Correct Answer: A
Rationale: The correct answer is A: Lung sounds. When a patient receives a hypertonic solution like 3% NaCl for hyponatremia, there is a risk of fluid shifting from the intravascular space to the interstitial spaces, potentially causing pulmonary edema and respiratory distress. Monitoring lung sounds is crucial to detect any signs of fluid overload and intervene promptly. B: Urinary output is important but not as critical as monitoring lung sounds in this context. C: Peripheral pulses and D: Peripheral edema are not directly related to the potential complications of receiving a hypertonic solution like 3% NaCl.
Question 2 of 5
A nurse reviews a client’s laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.)
Correct Answer: B
Rationale: Step-by-step rationale: 1. High-density lipoprotein (HDL) cholesterol is known as "good" cholesterol and lower levels are associated with increased risk of atherosclerosis. 2. HDL cholesterol of 50 mg/dL (1.3 mmol/L) is considered low and indicates a potential risk for atherosclerosis. 3. Atherosclerosis is characterized by the buildup of plaque in arteries, which can be influenced by cholesterol levels. 4. Total cholesterol and triglyceride levels are also important in assessing cardiovascular risk, but HDL cholesterol specifically is more indicative of atherosclerosis. 5. Serum albumin is not directly related to atherosclerosis. Summary: Choice B is correct as low HDL cholesterol levels are a key indicator of potential atherosclerosis risk. Choices A, C, and D are incorrect because they do not specifically relate to the risk of atherosclerosis.
Question 3 of 5
A patient with chronic obstructive pulmonary disease (COPD) has been eating very little and has lost weight. Which intervention would be most appropriate for the nurse to include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C, offering high-calorie protein snacks between meals and at bedtime. This intervention is most appropriate for a COPD patient who has lost weight due to poor intake. Proteins are essential for muscle maintenance and repair, and high-calorie snacks can help meet energy needs. Whole grains (A) may not provide enough calories, fruits and fruit juices (B) may not be calorie-dense, and foods with high vegetable content (D) may not provide sufficient protein or calories. In summary, option C addresses both the protein and calorie needs of the patient, making it the most suitable intervention.
Question 4 of 5
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Put on sterile gloves and use a sterile catheter to suction. When coarse crackles are heard in a patient with a tracheostomy tube and they are unable to clear secretions, suctioning is necessary to maintain airway patency and prevent complications like respiratory distress. Using a sterile catheter ensures aseptic technique to prevent infection. Choices A and B are not appropriate as they do not address the immediate need for airway clearance. Choice D is incorrect because preoxygenation before suctioning is not indicated in this scenario and may delay necessary intervention.
Question 5 of 5
The nurse teaches a patient who has asthma about peak flowmeter use. Which action by the patient indicates that teaching was successful?
Correct Answer: C
Rationale: The correct answer is C. When the patient uses albuterol for peak flows in the yellow zone, it indicates successful teaching because the yellow zone signifies caution, where the patient should take action to prevent worsening asthma symptoms. Using albuterol at this stage helps to manage symptoms before they escalate. Choice A is incorrect because inhaling rapidly through the peak flowmeter mouthpiece is not a correct technique and may lead to inaccurate results. Choice B is incorrect because montelukast is a controller medication and not used for immediate relief during asthma exacerbations. Choice D is incorrect because calling the healthcare provider when the peak flow is in the green zone is unnecessary as it indicates good lung function.