ATI RN
Introduction to Nursing Questions
Question 1 of 5
After securing the catheter to the client, the nurse should also secure the catheter to the bed linens and hang the urine drainage bag:
Correct Answer: C
Rationale: The correct answer is C: Below the level of the bladder. Securing the drainage bag below the level of the bladder helps maintain a continuous flow of urine by using gravity. Placing it above the bladder can lead to urinary stasis and potential backflow of urine. Securing it at the level of the bladder could cause pressure on the catheter, leading to discomfort and obstruction. Hanging the bag at any level the nurse prefers is not recommended as it doesn't follow best practice guidelines for urinary drainage.
Question 2 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 3 of 5
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
Correct Answer: A
Rationale: The correct answer is A: Assess the client for anxiety. The client's lack of comprehension, forgetfulness, and repetitive questioning are indicative of potential anxiety affecting their ability to process information. By assessing for anxiety, the nurse can address the underlying issue and provide appropriate support. Breaking information into smaller bits (B) may help but doesn't address the root cause. Giving written information (C) may not be effective if the client is experiencing anxiety. Simply reviewing the information again (D) without addressing the anxiety may not improve the client's understanding.
Question 4 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 5 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.