ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance?
Correct Answer: B
Rationale: The correct answer is B: Daily weight. Daily weight monitoring is the most accurate way to evaluate fluid balance in a patient with hypovolemia as it directly reflects changes in body fluid status. Weight changes are a sensitive indicator of fluid retention or loss. Skin turgor (A) is more indicative of dehydration rather than overall fluid balance. Urine output (C) is important but may not capture total fluid status. Edema presence (D) indicates fluid overload rather than hypovolemia.
Question 2 of 5
The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction?
Correct Answer: B
Rationale: The correct answer is B because using a heating pad on the feet can actually worsen PAD symptoms by dilating blood vessels and increasing blood flow, potentially leading to further ischemia. A: Choosing loose clothes helps improve circulation, as tight clothing can restrict blood flow. C: Walking to the point of pain and resting is a common exercise strategy for PAD patients. D: Changing positions frequently and avoiding prolonged sitting can prevent blood pooling and promote circulation.
Question 3 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 4 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 5 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.