ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select the one that does not apply.)
Correct Answer: D
Rationale: The correct answer is D: Red blood cells. Immunocompetence refers to the ability of the immune system to effectively respond to pathogens. Red blood cells are not directly involved in immune responses. Antibody-mediated immunity involves the production of antibodies by B cells to target pathogens. Cell-mediated immunity involves the activation of T cells to directly attack infected cells. Inflammation is a non-specific immune response that helps to eliminate pathogens. Red blood cells primarily function in oxygen transport and do not play a direct role in immune responses. Therefore, the correct answer is D as red blood cells do not need to be functional for a person to be immunocompetent.
Question 2 of 5
A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance?
Correct Answer: B
Rationale: The correct answer is B: Daily weight. Daily weight monitoring is the most accurate way to evaluate fluid balance in a patient with hypovolemia as it directly reflects changes in body fluid status. Weight changes are a sensitive indicator of fluid retention or loss. Skin turgor (A) is more indicative of dehydration rather than overall fluid balance. Urine output (C) is important but may not capture total fluid status. Edema presence (D) indicates fluid overload rather than hypovolemia.
Question 3 of 5
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
Correct Answer: A
Rationale: The correct answer is A: Lung sounds. When a patient receives a hypertonic solution like 3% NaCl for hyponatremia, there is a risk of fluid shifting from the intravascular space to the interstitial spaces, potentially causing pulmonary edema and respiratory distress. Monitoring lung sounds is crucial to detect any signs of fluid overload and intervene promptly. B: Urinary output is important but not as critical as monitoring lung sounds in this context. C: Peripheral pulses and D: Peripheral edema are not directly related to the potential complications of receiving a hypertonic solution like 3% NaCl.
Question 4 of 5
The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction?
Correct Answer: B
Rationale: The correct answer is B because using a heating pad on the feet can actually worsen PAD symptoms by dilating blood vessels and increasing blood flow, potentially leading to further ischemia. A: Choosing loose clothes helps improve circulation, as tight clothing can restrict blood flow. C: Walking to the point of pain and resting is a common exercise strategy for PAD patients. D: Changing positions frequently and avoiding prolonged sitting can prevent blood pooling and promote circulation.
Question 5 of 5
A nurse reviews a client’s laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.)
Correct Answer: B
Rationale: Step-by-step rationale: 1. High-density lipoprotein (HDL) cholesterol is known as "good" cholesterol and lower levels are associated with increased risk of atherosclerosis. 2. HDL cholesterol of 50 mg/dL (1.3 mmol/L) is considered low and indicates a potential risk for atherosclerosis. 3. Atherosclerosis is characterized by the buildup of plaque in arteries, which can be influenced by cholesterol levels. 4. Total cholesterol and triglyceride levels are also important in assessing cardiovascular risk, but HDL cholesterol specifically is more indicative of atherosclerosis. 5. Serum albumin is not directly related to atherosclerosis. Summary: Choice B is correct as low HDL cholesterol levels are a key indicator of potential atherosclerosis risk. Choices A, C, and D are incorrect because they do not specifically relate to the risk of atherosclerosis.