ATI RN
Introduction to Nursing 203 Quizlet Questions
Question 1 of 5
A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Perform chest physiotherapy every 4 hours. In CF patients, mucus buildup in the lungs can lead to respiratory distress. Chest physiotherapy helps loosen and clear the mucus, improving breathing. This intervention is essential in managing respiratory symptoms in CF patients. A: Schedule a sweat chloride test - This test is used to diagnose CF but is not an immediate intervention for a patient experiencing increased dyspnea. B: Arrange for a hospice nurse visit - Hospice care is not appropriate for a young adult with CF experiencing increased dyspnea unless the patient is in end-of-life care. C: Place the patient on a low-sodium diet - While nutrition is important in CF management, a low-sodium diet is not the priority when a patient is struggling to breathe.
Question 2 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 3 of 5
The nurse is performing an assessment on a patient brought to the emergency department for treatment for dehydration. The nurse assesses a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5 C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse notes cool, clammy skin. Which diagnosis does the nurse suspect?
Correct Answer: A
Rationale: The correct diagnosis is A: Fluid volume deficit (FVD). The patient's vital signs and symptoms indicate hypovolemia. A respiratory rate of 26 breaths/minute, heart rate of 110 beats/minute, low blood pressure, high temperature, dizziness upon position change, and cool, clammy skin are all indicative of FVD. The increased respiratory and heart rates are compensatory mechanisms to maintain oxygen delivery in response to decreased circulating volume. The low blood pressure and cool, clammy skin suggest poor perfusion due to decreased fluid volume. These findings align with the clinical presentation of dehydration. Summary of other choices: B: Fluid volume excess (FVE) - Contradicted by the patient's low blood pressure, cool, clammy skin, and symptoms of dehydration. C: Mild extracellular fluid (ECF) deficit - Symptoms and vital signs are indicative of severe rather than mild fluid deficit. D: Renal failure - Not supported by the information provided;
Question 4 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 5 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.