ATI RN
Introduction to Professional Nursing Quizlet Questions
Question 1 of 5
Helena is a post-surgical patient with a hemoglobin level of 7.6 g/dL and hematocrit of 25%. Today, she was prescribed with pRBC transfusion. You took the client’s temperature and it was at 38.2 C orally. Which of the following is the correct intervention?
Correct Answer: D
Rationale: The correct answer is D: Notify physician. Delay transfusion. Rationale: 1. Fever (temperature of 38.2 C) indicates possible infection or reaction to transfusion. 2. In a post-surgical patient, fever could be a sign of sepsis or transfusion reaction. 3. Delaying transfusion allows for further assessment and investigation by the physician. 4. Proceeding with transfusion without addressing the fever could worsen the patient's condition. Summary: - Choice A is incorrect because fever post-surgery is not normal and requires further evaluation. - Choice B is incorrect as administering anti-histamine does not address the underlying issue of fever. - Choice C is incorrect as giving Acetaminophen without further evaluation of the cause of fever is not appropriate.
Question 2 of 5
Nurse Corazon has just received a unit of packed red blood cells from the blood bank to transfuse into a client as ordered. Before preparing the blood for transfusion, Nurse Corazon noticed the presence of bubbles in the bag. She should take which of the following actions?
Correct Answer: C
Rationale: Rationale: 1. Bubbles in blood bag indicate possible contamination or improper handling. 2. Returning the bag to the blood bank ensures safety and quality control. 3. Adding saline or heparin can compromise the integrity of the blood product. 4. Double-checking by another nurse does not address the issue of bubbles. Summary: - Choice A: Does not address the potential issue with the blood bag. - Choice B: Adding saline can affect the blood product's composition. - Choice C: Correct - ensures proper handling and safety. - Choice D: Adding heparin can alter the blood product's function.
Question 3 of 5
A client has an order of small volume enema after an oral laxative fails to produce sufficient stool return. The nurse informs the client of the procedure. The client asks the nurse what small volume enema is all about. The nurse offered an APPROPRIATE answer when she states that small volume enema is:
Correct Answer: C
Rationale: The correct answer is C: Used to clean the sigmoid and rectum. Small volume enema is specifically designed to target the lower part of the colon, which includes the sigmoid colon and rectum. This type of enema is not meant to cleanse the entire colon like a large volume enema would. It is focused on providing relief and stimulation to the lower bowel to help with stool return. Explanation of incorrect choices: A: A laxative solution - Small volume enema is not just a laxative solution, it is a specific type of enema with a targeted purpose. B: Given to cleanse the colon - Small volume enema is not intended to cleanse the entire colon but rather the lower part. D: A commercially prepared enema - While small volume enemas can be commercially prepared, this choice does not address the specific purpose of the enema, which is to clean the sigmoid and rectum.
Question 4 of 5
During the planning step of the nursing process, the nurse performs which activity?
Correct Answer: B
Rationale: During the planning step of the nursing process, the nurse develops goals of care to address the patient's needs identified during data collection and analysis. This step involves setting specific, measurable, achievable, relevant, and time-bound objectives to guide the care provided. Developing goals of care ensures that the care plan is individualized, patient-centered, and focused on achieving positive outcomes for the patient. Recording data (A) is part of the assessment phase, collecting data (C) is part of the assessment phase, and carrying out interventions (D) is part of the implementation phase of the nursing process, not the planning phase.
Question 5 of 5
The nurse is assessing the client who has edema. The skin remains indented or pitted at 8mm. The nurse describes the degree of edema as:
Correct Answer: D
Rationale: The correct answer is D (4+). This degree of edema indicates severe pitting edema where the skin remains indented or pitted at 8mm. This level of indentation signifies a significant accumulation of fluid in the tissues. Choices A (1+), B (2+), and C (3+) represent varying degrees of pitting edema with shallower indentations ranging from 2mm to 6mm, which are considered mild to moderate levels of edema. Therefore, the correct assessment of 4+ reflects the severity of the client's condition based on the depth of indentation and the amount of accumulated fluid in the tissues.