ATI RN
Introduction to Nursing Chapter 1 Quizlet Questions
Question 1 of 5
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?
Correct Answer: A
Rationale: The correct answer is A: Airway. Priority in postoperative assessment is airway patency to ensure oxygenation and prevent airway obstruction. The rationale is based on the ABCs (Airway, Breathing, Circulation) of prioritizing patient care. Ensuring a clear airway is essential for adequate oxygenation and ventilation, preventing hypoxia and respiratory distress. Bleeding (B) can be addressed once airway is secured. Breathing (C) is important but comes after ensuring the airway. Cardiac rhythm (D) is important but is secondary to airway assessment in this situation.
Question 2 of 5
A patient at the clinic says, “I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though.” What focused assessment should the nurse make?
Correct Answer: D
Rationale: The correct answer is D because the patient's symptoms suggest a possible vascular issue, such as peripheral arterial disease (PAD). Palpating for the dorsalis pedis and posterior tibial pulses can help assess the adequacy of blood flow in the lower extremities. A decrease or absence of these pulses may indicate compromised blood flow, leading to symptoms like leg cramps and pain with activity. Choices A, B, and C are incorrect because they do not directly address the patient's symptoms of leg cramps and pain with walking, which are suggestive of a vascular etiology. Looking for tortuous veins, skin color changes in response to cold, or unilateral swelling, redness, and tenderness may be indicative of other conditions like varicose veins, Raynaud's phenomenon, or deep vein thrombosis, respectively. However, these symptoms are not consistent with the patient's presentation in this scenario.
Question 3 of 5
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
Correct Answer: D
Rationale: The correct interpretation of the arterial blood gas results provided is respiratory alkalosis (Choice D). 1. pH is high (alkalosis) at 7.48, indicating respiratory alkalosis. 2. PaO2 is within normal range, ruling out any significant oxygenation issues. 3. PaCO2 is low at 32 mm Hg, indicating respiratory alkalosis. 4. HCO3 is within normal range at 25 mEq/L, not indicative of metabolic acid-base imbalance. Summary: - Choice A (Metabolic acidosis) is incorrect as HCO3 is within normal range. - Choice B (Metabolic alkalosis) is incorrect as HCO3 is within normal range. - Choice C (Respiratory acidosis) is incorrect as PaCO2 is low, indicating alkalosis.
Question 4 of 5
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that do not apply.)
Correct Answer: D
Rationale: The correct answer is D because household light bulbs being fluorescent type is not directly related to safety when using oxygen at home. Oxygen supports combustion and can increase fire risk. A, B, and C are important safety factors as smoking can ignite oxygen, damaged electrical cords can cause sparks, and flammable liquids can also lead to fires.
Question 5 of 5
Which action should the nurse take first when a patient develops epistaxis?
Correct Answer: B
Rationale: The correct action for a patient with epistaxis is to apply squeezing pressure to the nostrils for 10 minutes. This helps to control the bleeding by applying direct pressure to the affected blood vessels. It is the initial and most immediate intervention to stop the bleeding. Packing the nare with an epistaxis balloon (choice A) or obtaining silver nitrate for cauterization (choice C) are more invasive measures that should be considered if bleeding persists after applying pressure. Instilling a vasoconstrictor medication (choice D) may help in some cases but is not the first-line intervention.