ATI RN
Introduction to Nursing Chapter 1 Quizlet Questions
Question 1 of 5
After the blood transfusion, you assessed the client for blood transfusion reactions. The following assessments were noted: HR: 120 bpm, Pulse: +4 in quality, presence of fine, short, high pitched crackling at base. Which of the following is your FIRST action?
Correct Answer: D
Rationale: The correct first action is D: Consult with the primary health care provider (PHCP) regarding initiation of oxygen therapy. This is because the client is showing signs of a potential transfusion reaction, likely a pulmonary embolism. The client's rapid heart rate, bounding pulse, and crackling sound at the base suggest a possible pulmonary issue. Oxygen therapy is crucial to improve oxygenation and stabilize the client's condition. Consulting with the PHCP ensures timely intervention and appropriate management. A: Maintaining bed rest with legs elevated would not address the potential respiratory distress the client is experiencing. B: Placing the client in high-Fowler's position may help improve oxygenation, but consulting the PHCP for oxygen therapy is the priority. C: Increasing the rate of IV fluids is not the priority when the client is showing signs of a potential serious complication like a pulmonary embolism.
Question 2 of 5
At 8:00 a.m., Nurse Corazon is preparing to change the Total Parenteral Nutrition (TPN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse would instruct the client to do which of the following during the tubing change?
Correct Answer: C
Rationale: The correct answer is C: Ask the client to take a deep breath, hold, and bear down during the tubing change. This action helps to prevent air embolism by increasing intrathoracic pressure, which reduces the risk of air being drawn into the central venous line. When the client bears down, the pressure in the thorax increases, preventing air from being sucked into the vein. Choices A, B, and D are incorrect because they do not address the specific action needed to prevent air embolism during the tubing change. Breathing normally (choice A) or turning the head to the right (choice B) will not help in preventing air embolism. Exhaling slowly and evenly (choice D) does not provide the necessary increase in intrathoracic pressure to prevent air entry into the central venous line.
Question 3 of 5
A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client?
Correct Answer: C
Rationale: The correct answer is C: Deficient fluid volume related to nausea and vomiting. Priority is given to addressing fluid volume deficits to prevent dehydration and electrolyte imbalances. Nausea, vomiting, and fever can lead to significant fluid loss. Choice A is incorrect as excessive fluid volume is not indicated. Choice B is incorrect as addressing nutrition would come after addressing fluid volume. Choice D is incorrect as hyperventilation does not typically lead to ineffective cardiopulmonary tissue perfusion in this scenario.
Question 4 of 5
While caring for a client who's immobile, the nurse documents the following information in the client's chart: Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." This nursing diagnosis accurately reflects the potential of:"
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity related to immobility. The nurse's documentation indicates preventive measures taken to maintain skin integrity due to immobility, such as turning the client every 2 hours. The absence of redness and improved skin turgor show proactive skin assessment and care. Choice B is incorrect as there is no evidence of actual skin breakdown. Constipation (choice C) and disturbed body image (choice D) are not supported by the information provided. Therefore, choice A is the most appropriate nursing diagnosis based on the documented care and assessment findings.
Question 5 of 5
A 60-year old client reports to the nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blister like lesions that are filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?
Correct Answer: D
Rationale: The correct answer is D: Vesicles. Vesicles are small, elevated lesions filled with clear fluid, typically less than 0.5 cm in diameter. In this case, the client's presentation of elevated, round, blister-like lesions filled with clear fluid matches the description of vesicles. Pustules (A) are similar in appearance but contain pus, while papules (B) are raised, solid lesions without fluid-filled cavities. Plaques (C) are flat, raised lesions typically larger than 1 cm in diameter. Therefore, based on the specific characteristics of the lesions described in the scenario, the appropriate term to use would be vesicles.