ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
A postoperative patient has ineffective airway clearance. Which data would indicate to the nurse that interventions for this patient problem have been successful?
Correct Answer: C
Rationale: The correct answer is C because clear breath sounds indicate effective airway clearance. Clear breath sounds suggest that air is flowing freely through the airways, indicating successful interventions. A: Fluid intake does not directly reflect airway clearance. B: Using a spirometer may improve lung function but does not necessarily indicate effective airway clearance. D: Temperature is not directly related to airway clearance.
Question 2 of 5
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
Correct Answer: A
Rationale: The correct answer is A: Lung sounds. When a patient receives a hypertonic solution like 3% NaCl for hyponatremia, there is a risk of fluid shifting from the intravascular space to the interstitial spaces, potentially causing pulmonary edema and respiratory distress. Monitoring lung sounds is crucial to detect any signs of fluid overload and intervene promptly. B: Urinary output is important but not as critical as monitoring lung sounds in this context. C: Peripheral pulses and D: Peripheral edema are not directly related to the potential complications of receiving a hypertonic solution like 3% NaCl.
Question 3 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 4 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 5 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.