ATI RN
Introduction to Nursing Chapter 1 Quizlet Questions
Question 1 of 5
How long should a suction attempt be limited to?
Correct Answer: B
Rationale: The correct answer is B: 15 seconds. Suction attempts should generally be limited to 15 seconds to prevent hypoxia and tissue damage. Prolonged suctioning can lead to decreased oxygenation and potential trauma to the airway. Choice A (5 seconds) may not be sufficient for effective suctioning. Choice C (30 seconds) and D (1 minute) exceed the recommended time limit and increase the risk of complications. Therefore, choice B is the most appropriate duration for a suction attempt.
Question 2 of 5
Mrs. David is obese. When administering a subcutaneous injection to an obese patient, it is best for Nurse Andrae to:
Correct Answer: D
Rationale: The correct answer is D. When administering a subcutaneous injection to an obese patient, it is best for Nurse Andrae to spread or pinch the skin at the injection site and inject the needle at a 45-90 degree angle. This allows for proper medication absorption due to the thicker layer of subcutaneous fat in obese patients. Pinching the skin helps ensure the medication is injected into the subcutaneous tissue rather than the muscle. Options A and B are not ideal for obese patients as they may not penetrate the thicker layer of fat effectively. Option C, the Z track method, is typically used for intramuscular injections and is not necessary for subcutaneous injections in obese patients.
Question 3 of 5
At 8:00 a.m., Nurse Corazon is preparing to change the Total Parenteral Nutrition (TPN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse would instruct the client to do which of the following during the tubing change?
Correct Answer: C
Rationale: The correct answer is C: Ask the client to take a deep breath, hold, and bear down during the tubing change. This action helps to prevent air embolism by increasing intrathoracic pressure, which reduces the risk of air being drawn into the central venous line. When the client bears down, the pressure in the thorax increases, preventing air from being sucked into the vein. Choices A, B, and D are incorrect because they do not address the specific action needed to prevent air embolism during the tubing change. Breathing normally (choice A) or turning the head to the right (choice B) will not help in preventing air embolism. Exhaling slowly and evenly (choice D) does not provide the necessary increase in intrathoracic pressure to prevent air entry into the central venous line.
Question 4 of 5
A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client?
Correct Answer: C
Rationale: The correct answer is C: Deficient fluid volume related to nausea and vomiting. Priority is given to addressing fluid volume deficits to prevent dehydration and electrolyte imbalances. Nausea, vomiting, and fever can lead to significant fluid loss. Choice A is incorrect as excessive fluid volume is not indicated. Choice B is incorrect as addressing nutrition would come after addressing fluid volume. Choice D is incorrect as hyperventilation does not typically lead to ineffective cardiopulmonary tissue perfusion in this scenario.
Question 5 of 5
While caring for a client who's immobile, the nurse documents the following information in the client's chart: Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." This nursing diagnosis accurately reflects the potential of:"
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity related to immobility. The nurse's documentation indicates preventive measures taken to maintain skin integrity due to immobility, such as turning the client every 2 hours. The absence of redness and improved skin turgor show proactive skin assessment and care. Choice B is incorrect as there is no evidence of actual skin breakdown. Constipation (choice C) and disturbed body image (choice D) are not supported by the information provided. Therefore, choice A is the most appropriate nursing diagnosis based on the documented care and assessment findings.