ATI RN
Introduction to Nursing Questions
Question 1 of 5
A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Perform a bladder scan. The first step is to assess the patient's bladder volume non-invasively before considering invasive procedures like catheterization. A bladder scan will provide information about the patient's bladder volume and guide further interventions. Choice B (Insert a straight catheter) is incorrect as this is an invasive procedure and should not be the first action without assessing the bladder volume. Choice C (Encourage increased oral fluid intake) is incorrect as it does not address the immediate need to assess the patient's bladder status. Choice D (Assist the patient to ambulate to the bathroom) is incorrect as this may not resolve the issue if the patient has bladder retention.
Question 2 of 5
A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound?
Correct Answer: D
Rationale: The correct answer is D: Multi-fiber superabsorbent dressing. This type of dressing is ideal for a wound with copious exudate as it can effectively absorb and contain the excessive fluid. It helps maintain a moist wound environment conducive to healing while preventing maceration. Wet-to-damp gauze (A) can cause trauma upon removal. Leaving the wound open (B) increases the risk of infection. Transparent film (C) may not provide enough absorbency for a wound with high exudate.
Question 3 of 5
The nurse is reviewing drug therapy for hypertension. According to the JNC-8 guidelines, antihypertensive drug therapy for a newly diagnosed hypertensive African-American patient would most likely include which drug or drug classes?
Correct Answer: C
Rationale: The correct answer is C: Calcium channel blockers with thiazide diuretics. According to JNC-8 guidelines, for African-American patients with hypertension, initial drug therapy should include calcium channel blockers or thiazide diuretics due to their proven efficacy in this population. Calcium channel blockers help relax blood vessels and improve blood flow, while thiazide diuretics help reduce fluid volume and blood pressure. This combination has shown better outcomes and reduced risk of adverse effects in African-American patients. Incorrect choices: A: Vasodilators alone - Not recommended as initial therapy for newly diagnosed hypertensive African-American patients. B: ACE inhibitors alone - While ACE inhibitors are effective in treating hypertension, they are not the first-line choice for African-American patients based on JNC-8 guidelines. D: Beta blockers with thiazide diuretics - Beta blockers are not the preferred initial therapy for hypertensive African-American patients according to JNC-8 guidelines.
Question 4 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 5 of 5
The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data should be of most concern to the nurse?
Correct Answer: B
Rationale: The correct answer is B: Blood pressure is 90/40 mm Hg. This is the most concerning assessment data because it indicates hypotension, which can be a sign of hypovolemic shock in a patient with massive burn injury. Hypotension can lead to inadequate tissue perfusion and organ failure. Choice A is not as concerning as low urine output can be expected in a hypovolemic patient. Choice C is not as critical as oral fluid intake may vary, but IV fluids can be administered if needed. Choice D, skin tenting, is a sign of dehydration but is not as immediately life-threatening as hypotension.