ATI RN
Introduction to Nursing Questions
Question 1 of 5
A patient with aortic stenosis has acute pain due to decreased coronary blood flow. What would be an appropriate nursing intervention for this patient?
Correct Answer: A
Rationale: Correct Answer: A: Promote rest to decrease myocardial oxygen demand. Rationale: 1. Aortic stenosis leads to decreased coronary blood flow, causing myocardial ischemia and pain. 2. Rest decreases myocardial oxygen demand, reducing the workload on the heart. 3. By promoting rest, the body's oxygen demand decreases, helping to alleviate the acute pain. 4. Teaching about anticoagulant therapy (B) and nitroglycerin use (C) are not directly related to addressing decreased coronary blood flow. 5. Raising the head of the bed (D) to decrease venous return would not directly address the underlying issue of decreased coronary blood flow and acute pain.
Question 2 of 5
A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first?
Correct Answer: D
Rationale: The correct answer is D. The nurse should assess the 27-year-old client with a heart rate of 120 beats/min first as an elevated heart rate can indicate respiratory distress or other serious underlying conditions. This assessment is crucial for immediate intervention. A: A 66-year-old client with a barrel chest and clubbed fingernails may indicate chronic obstructive pulmonary disease but does not require immediate attention compared to a high heart rate. B: A 48-year-old client with an oxygen saturation level of 92% at rest indicates potential hypoxemia but does not pose an immediate threat as the client is at rest. C: A 35-year-old client reporting orthopnea indicates difficulty breathing when lying flat, which is concerning but less urgent compared to a high heart rate.
Question 3 of 5
Which information will be most important for the nurse to communicate to the health care provider about an older patient who has influenza?
Correct Answer: B
Rationale: The correct answer is B: Diffuse crackles in the lungs. This is the most important information to communicate because it indicates a potential complication like pneumonia in older patients with influenza. Crackles suggest fluid accumulation in the lungs, requiring prompt medical attention. Fever (A) and myalgia/headache (D) are common symptoms of influenza but may not indicate severe complications. Sore throat and cough (C) are typical symptoms and do not directly point to a serious issue like lung involvement.
Question 4 of 5
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
Correct Answer: B
Rationale: The correct answer is B: Ensure that informed consent is on the chart. This is the priority because obtaining informed consent is a legal and ethical requirement before any invasive procedure. It ensures the client understands the procedure, risks, benefits, and alternatives. Administering anxiolytic medication can help with anxiety but is not the priority. Reinforcing teaching and starting preoperative antibiotics are important but come after ensuring informed consent to prioritize the client's autonomy and safety.
Question 5 of 5
A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Assess the client's airway. This is the priority action because airway patency is always the top priority in any emergency situation. In this case, the packing for posterior nasal bleeding could potentially obstruct the client's airway, leading to respiratory distress or compromise. By assessing the client's airway first, the nurse can ensure that the client is able to breathe effectively. Choice A: Assessing the client's pain level is important but not the first priority in this situation. Choice B: Keeping the client's head elevated may be beneficial, but it is not the immediate priority over assessing the airway. Choice C: Teaching the client about the causes of nasal bleeding is important for education but not urgent in this situation.