ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?
Correct Answer: C
Rationale: The correct answer is C because positioning an unconscious patient on the side in the PACU helps prevent aspiration and ensures proper airway management. This position also promotes optimal ventilation and prevents airway obstruction. Choice A is incorrect because assisting a nauseated patient to a supine position can increase the risk of aspiration. Choice B is incorrect because placing a sleeping patient supine with the head elevated does not address airway protection for an unconscious patient. Choice D is incorrect as placing a patient in Trendelenburg position for low blood pressure is not recommended without a specific indication and can increase intracranial pressure in some cases.
Question 2 of 5
While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient’s bed elevated 45 degrees. What does this finding indicate?
Correct Answer: C
Rationale: Step 1: Jugular venous distention (JVD) is often indicative of increased pressure in the right atrium. Step 2: Elevating the head of the bed to 45 degrees helps accentuate JVD, making it easier to observe. Step 3: Increased right atrial pressure can be caused by conditions like heart failure or tricuspid valve regurgitation. Step 4: This finding is significant in older adults as they are more prone to cardiovascular issues. Summary: Choice A is incorrect as JVD typically indicates fluid overload, not decreased volume. Choice B is incorrect as atherosclerosis affects arteries, not veins. Choice D is incorrect as incompetent jugular vein valves would lead to backflow, not distention.
Question 3 of 5
An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram?(Select the one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A. Hypertension alone may not directly warrant an electrocardiogram (ECG) as it primarily indicates high blood pressure. However, fatigue despite adequate rest, indigestion, and abdominal pain can be symptoms of underlying cardiac issues that require an ECG for further evaluation. Fatigue can be a sign of heart problems affecting oxygen delivery, while indigestion and abdominal pain can be symptoms of a heart attack or other cardiac conditions. Requesting an ECG based on these symptoms can help identify potential cardiac issues early on.
Question 4 of 5
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that do not apply.)
Correct Answer: A
Rationale: Step-by-step rationale: 1. Chest x-ray is not routinely scheduled annually for monitoring complications in type 2 diabetes. 2. Blood pressure monitoring is essential for assessing cardiovascular risk in diabetic patients. 3. Serum creatinine levels are checked annually to assess kidney function. 4. Urine for microalbuminuria is done annually to detect early signs of kidney damage. 5. Since chest x-ray is not directly related to diabetes complications, it is the correct answer. Summary: A is correct because chest x-ray is not a standard test for monitoring type 2 diabetes complications. B, C, and D are incorrect as they are essential for evaluating cardiovascular risk, kidney function, and early signs of kidney damage in diabetic patients.
Question 5 of 5
Which action should the nurse plan to prevent aspiration in a high-risk patient?
Correct Answer: B
Rationale: The correct answer is B: Place a patient with altered consciousness in a side-lying position. This position helps prevent aspiration by reducing the risk of regurgitated material entering the airway. Patients with altered consciousness are at higher risk of aspiration due to impaired protective airway reflexes. Placing them in a side-lying position helps maintain an open airway and facilitates drainage of secretions. Incorrect choices: A: Turning and repositioning an immobile patient every 2 hours is important for preventing pressure ulcers, not aspiration. C: Inserting a nasogastric tube for feeding does not directly prevent aspiration; it is a method of providing nutrition. D: Monitoring respiratory symptoms in an immunosuppressed patient is important for detecting infections but does not directly prevent aspiration.