ATI RN
Introduction to Nursing Questions
Question 1 of 5
How is 6mm of skin indentation described in terms of edema?
Correct Answer: D
Rationale: The correct answer is D (4+). In terms of edema, a 4+ indentation signifies severe pitting edema. This level of indentation indicates that the skin remains indented for a significant period after pressure is applied, suggesting the presence of extensive fluid accumulation in the tissues. Choices A, B, and C are incorrect because they represent lesser degrees of pitting edema, with A being mild (1+), B being moderate (2+), and C being more significant (3+), but still not as severe as 4+. Therefore, the correct choice D is determined by the depth and persistence of the skin indentation, indicating the severity of edema present.
Question 2 of 5
When preparing for a subcutaneous injection, the proper size of syringe and needle would be:
Correct Answer: D
Rationale: The correct answer is D because for subcutaneous injections, a syringe volume of 1-3ml is sufficient for most medications. The needle gauge of 25-27 is appropriate for subcutaneous injections as it is thin enough to minimize discomfort but thick enough to allow for proper medication flow. Tuberculin syringes are typically used for intradermal injections, not subcutaneous. Syringe sizes in choices A and C are larger than necessary for subcutaneous injections, which can lead to unnecessary wastage of medication. Needle gauges in choices A and C are also thicker than needed for subcutaneous injections, potentially causing more pain and tissue damage.
Question 3 of 5
Nurse Corazon is making initial rounds at the beginning of the shift. She enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the bag is empty. Which of the following solutions readily available on the nursing unit should the she hang until another TPN solution is mixed and delivered to the nursing unit?
Correct Answer: B
Rationale: The correct answer is B: 5% dextrose in water. When a TPN bag is empty, it is important to prevent hypoglycemia by providing a temporary source of glucose until a new TPN solution can be prepared. 5% dextrose in water is the appropriate choice as it provides a low concentration of glucose to maintain blood sugar levels without overloading the patient with excessive dextrose. Option A, 10% dextrose in water, is too concentrated and may cause hyperglycemia in the patient. Option C, 5% dextrose in 0.9% sodium chloride, is not ideal as the patient on TPN does not need additional sodium and chloride in the solution. Option D, None of the above, is incorrect as providing no solution would leave the patient at risk of hypoglycemia.
Question 4 of 5
A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?
Correct Answer: A
Rationale: The correct answer is A because it directly addresses the nursing diagnosis by focusing on the client's ability to identify potassium-rich food sources, which is crucial in managing the risk for injury related to potassium-wasting diuretics. The outcome is specific, measurable, and achievable, aligning with the SMART criteria for goal setting. Choice B is incorrect as it does not specify a measurable action related to potassium-rich foods. Choice C lacks the specificity of identifying the number of potassium-rich food sources. Choice D is incorrect as it does not directly address the nursing diagnosis and focuses on a different aspect of the client's understanding.
Question 5 of 5
Which nursing diagnosis would comply with guidelines set forth by NANDA?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury related to generalized weakness. This diagnosis complies with NANDA guidelines as it is specific, measurable, and based on clinical judgment. It focuses on the potential harm a patient may experience due to their weakness, aligning with NANDA's criteria for nursing diagnoses. The other choices lack specificity and do not directly address the patient's actual health problem. Choice A assumes the cause of ineffective airway clearance without assessment data. Choice B involves psychological factors not directly related to a physiological condition. Choice C implies a behavioral issue rather than a potential health risk.