ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
Correct Answer: C
Rationale: The correct answer is C because during an acute episode of respiratory distress, it is essential to quickly gather specific information about the current situation. This allows the nurse to assess the severity of the issue, identify potential causes, and provide immediate interventions. Asking specific questions about the episode helps in determining the onset, triggers, associated symptoms, and any previous similar episodes. This information guides the nurse in prioritizing care and initiating appropriate interventions promptly. Choice A is incorrect because asking the patient to lie down for a full physical assessment is not appropriate during acute respiratory distress as it delays crucial information gathering. Choice B is incorrect as completing the health history and checking for allergies can be done after addressing the immediate respiratory distress. Choice D is incorrect because delaying the physical assessment for pulmonary function tests is not indicated in the acute management of respiratory distress.
Question 2 of 5
A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate?
Correct Answer: C
Rationale: Rationale: Option C is correct because xerostomia (dry mouth) is a common side effect of radiation therapy to the head and neck area. It is important for the nurse to educate the client about this potential side effect and provide strategies for managing it. This includes encouraging the client to stay hydrated, suck on sugar-free candy, and avoid alcohol and tobacco. Option A is incorrect as lidocaine-containing mouthwash may not be appropriate for long-term use and may not effectively address the underlying issue of dry mouth. Option B is also incorrect as IV fluid boluses are not indicated for managing dry mouth. Option D is incorrect as assessing the client's neck for redness and swelling is not directly related to the client's complaint of dry mouth.
Question 3 of 5
An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best?
Correct Answer: A
Rationale: The correct answer is A: Assess the client's lung sounds. This is the best action because coughing during a meal with a tracheostomy could indicate aspiration, which can lead to respiratory complications. Assessing lung sounds can help determine if there are any signs of respiratory distress. B: Assign a different AP to the client - This is not the best action as the priority is to assess the client's condition first. C: Report the AP to the manager - This is not the best action as the immediate concern is the client's well-being and assessing their condition. D: Request thicker liquids for meals - This is not the best action as it does not address the potential respiratory issue the client may be experiencing.
Question 4 of 5
Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?
Correct Answer: C
Rationale: The correct answer is C. New onset shortness of breath is concerning for a pulmonary embolism, a serious complication of VTE. The nurse should act immediately to assess the patient's respiratory status and initiate appropriate interventions. A: Report of right calf pain is expected with VTE and does not require immediate action. B: Erythema of right lower leg can be a sign of inflammation but does not necessitate urgent intervention. D: Temperature of 100.4° F is a low-grade fever, which may indicate an infection but does not require immediate action in this context.
Question 5 of 5
Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina?
Correct Answer: D
Rationale: Step 1: Chronic stable angina is chest pain relieved by rest or nitroglycerin due to reduced blood flow to the heart. Step 2: Choice D indicates pain relieved by nitroglycerin, a hallmark of angina. Step 3: Choices A, B, and C do not specifically confirm angina diagnosis. Summary: Choice D is correct as it directly aligns with the characteristic relief of angina pain with nitroglycerin. Choices A, B, and C do not provide direct confirmation of chronic stable angina.