ATI RN
Introduction to Nursing 203 Quizlet Questions
Question 1 of 5
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-Ib weight gain in the past 3 days. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Assess the patient for manifestations of acute heart failure. In this scenario, the patient's sudden weight gain could indicate fluid retention, a common sign of acute heart failure exacerbation. Assessing the patient for other symptoms such as shortness of breath, increased fatigue, or edema can help determine if the patient's condition is worsening. This immediate assessment is crucial for prompt intervention to prevent further complications. Choices A, C, and D are incorrect as they do not address the urgency of the situation. Teaching about sodium restriction is important but not the priority in this acute situation. Asking about medication use and dietary intake can wait until the immediate concern of acute heart failure exacerbation is addressed.
Question 2 of 5
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient’s ventilation?
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to sit in a chair and lean forward. This position helps improve ventilation by expanding the chest cavity, allowing for better lung expansion and increased air exchange. Leaning forward also reduces pressure on the diaphragm, making it easier for the patient to breathe. Choice B (head elevated 15 degrees) does not provide as much chest expansion as leaning forward. Choice C (Trendelenburg position) places the patient with their head lower than the feet, which can worsen breathing difficulties. Choice D (high-Fowler’s position with knees flexed) does not promote optimal lung expansion compared to leaning forward. In summary, choice A is the best option as it maximizes chest expansion and supports ventilation in a patient with poor gas exchange due to COPD.
Question 3 of 5
The client is to receive a scheduled dose of digoxin has a irregular apical pulse of 92 bpm and a serum potassium of 3.9 meq/l which nursing documentation reflects the most appropriate action?
Correct Answer: A
Rationale: Rationale: 1. Digoxin is indicated for rapid apical pulse. 2. Digoxin has narrow therapeutic range. 3. Potassium level is within normal limits (WNL). 4. Notifying physician or holding digoxin may delay treatment. 5. Monitoring for toxicity is not proactive. 6. Rechecking pulse in 1 hour is unnecessary and may lead to delay in treatment. Summary: Choice A is correct because the potassium level is normal and digoxin is appropriate for rapid pulse. Choices B, C, and D are incorrect as they may delay necessary treatment or not address the current situation effectively.
Question 4 of 5
A patient who has just undergone a colon resection complains to a nurse that he felt something pop under his dressing while trying to get out of bed.the nurse removes the dressing and finds that dehiscence of the wound has occurred.what nursing action should be implemented first?
Correct Answer: A
Rationale: The correct answer is A: Cover the wound with sterile dressings saturated with normal saline. This action helps to maintain a moist environment for wound healing and prevent further contamination. The step-by-step rationale is: 1) Covering the wound with sterile dressings helps protect the wound from infection and further trauma. 2) Saturating the dressings with normal saline helps keep the wound moist, promoting healing. 3) This immediate action is crucial in preventing complications such as infection and further wound dehiscence. Summary of other choices: B: Notifying the surgeon immediately is important, but covering the wound to protect it should be done first. C: Applying pressure to the wound can further damage the tissue and should not be done. D: Placing the patient in Trendelenburg position is not necessary for wound dehiscence and does not address the immediate need to protect the wound.
Question 5 of 5
A nurse in a walk-in healthcare setting provides technical services, such as, administering medications, determines the priority of care needs, and provides patient teaching on all aspects of care. Which of the following terms best describes this type of healthcare setting?
Correct Answer: C
Rationale: The correct answer is C: ambulatory center. This setting is best described as an ambulatory center because it provides same-day medical services without the need for an overnight stay. Ambulatory centers offer a wide range of medical services, including administering medications, determining care priorities, and patient education. Hospitals (choice A) typically provide more acute care services requiring overnight stays. Physicians' offices (choice B) usually offer routine check-ups and consultations but may not provide the same level of technical services as an ambulatory center. Long-term care facilities (choice D) focus on providing extended care for individuals who require ongoing assistance with daily activities, which is not the primary function of the described healthcare setting.