ATI RN
Introduction to Nursing Pdf Questions
Question 1 of 5
Bathing a client provides an excellent opportunity to assess the client's integument. Which finding indicates the need for referral to another health care professional?
Correct Answer: D
Rationale: The correct answer is D: Cheilosis. Cheilosis refers to inflammation and fissuring at the corners of the mouth, which can indicate a vitamin deficiency or fungal infection. This finding may require referral to a healthcare professional for further evaluation and treatment. A, B, and C are incorrect choices because flaky skin, rough skin in exposed areas, and hirsutism of the chin, and pitting edema of the ankles and feet are common skin conditions that can be addressed by a nurse during bathing without the need for immediate referral to another healthcare professional.
Question 2 of 5
A patient is ordered to receive an intravenous infusion of 3,000 cc 0.8% NaCl over 24 hours. The nurse observes that the rate is 150 cc/hr. If the infusion runs continuously at this rate, the nurse would expect the infusion to be completed in:
Correct Answer: B
Rationale: To calculate the total time for the infusion, you divide the total volume (3,000 cc) by the infusion rate (150 cc/hr). 3000 cc ÷ 150 cc/hr = 20 hours. Therefore, the correct answer is B: 20 hours. Choice A (12 hours) is incorrect as it underestimates the time needed. Choice C (24 hours) is incorrect as it is the total duration of the infusion, not the time to complete it. Choice D (50 hours) is incorrect as it overestimates the time required.
Question 3 of 5
A nurse in the ICU is caring for a patient with PEEP. The patient suddenly called the nurse, and said: “Nurse, my leg is severely aching!” What is your priority nursing action?
Correct Answer: C
Rationale: The correct answer is C: Check the balloon of the ET tube. This is the priority nursing action because PEEP (Positive End-Expiratory Pressure) is a mechanical ventilation setting that can lead to accidental migration of the endotracheal (ET) tube, causing pressure on surrounding structures like the vocal cords or trachea, leading to referred pain in the leg. Checking the balloon of the ET tube ensures proper placement and prevents complications. Choice A: Checking the condition of the leg is not the priority as the patient's complaint is likely related to the mechanical ventilation. Choice B: Checking for pain scale is not the priority as addressing the source of the pain is more critical. Choice D: Giving analgesic is not appropriate until the cause of the leg pain is identified.
Question 4 of 5
What is the priority of care after the urinary catheter is removed?
Correct Answer: C
Rationale: The correct answer is C because after urinary catheter removal, priority is to evaluate the client for normal voiding to ensure proper bladder function. Encouraging fluid intake (A) is important for hydration. Documenting catheter size and client tolerance (B) is relevant but not a priority post-catheter removal. Documenting client teaching (D) is important but not the immediate priority.
Question 5 of 5
The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal?
Correct Answer: B
Rationale: The correct answer is B: Urine pH of 3.0 is abnormal. Normal urine pH ranges from 4.6 to 8.0. A pH of 3.0 indicates highly acidic urine, which may be indicative of certain health conditions. Specific gravity of 1.03 is within the normal range (1.005-1.030). Absence of protein and glucose in urine is normal. Proteinuria and glucosuria are typically abnormal findings.