ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
In assessing oral temperature, how long should the nurse wait prior to reading the thermometer?
Correct Answer: C
Rationale: The correct answer is C (2-3 minutes). After placing the oral thermometer under the tongue, waiting for 2-3 minutes allows for an accurate reading of the oral temperature to be obtained. This timeframe ensures that the thermometer has enough time to accurately measure the body temperature. A (30 seconds) is too short for an accurate reading as it may not provide enough time for the thermometer to stabilize. B (1 full minute) is also not sufficient for an accurate reading. D (10 minutes) is too long and unnecessary, as it can lead to discomfort for the patient and does not improve the accuracy of the reading.
Question 2 of 5
A 3 year-old child is brought to the clinic by his grandmother to be seen for scratching his bottom and wetting the bed at night." Based on these complaints
Correct Answer: D
Rationale: The correct answer is D: Regression. In this scenario, the child is showing behaviors such as scratching his bottom and bedwetting, which are common signs of regression in young children. Regression often occurs in response to stress or changes in the child's environment. By selecting this answer, the nurse can explore potential stressors in the child's life and provide appropriate support. A: Not the initial assessment as the symptoms are indicative of a psychological issue rather than a physical problem. B: Allergies are unlikely to cause both scratching bottom and bedwetting. C: Scabies may cause itching but is less likely to cause bedwetting.
Question 3 of 5
The nurse further asked the client to move her tongue side to side & up and down. The nurse is checking what cranial nerve with this process?
Correct Answer: B
Rationale: The correct answer is B: Glossopharyngeal nerve. Moving the tongue side to side & up and down tests the function of the glossopharyngeal nerve (cranial nerve IX), responsible for controlling the muscles of the tongue and throat. The other choices are incorrect because: A: Facial nerve (VII) controls facial expressions, not tongue movements. C: Trigeminal nerve (V) controls chewing and sensation in the face, not tongue movement. D: Abducens nerve (VI) controls eye movement, not tongue movements.
Question 4 of 5
When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?
Correct Answer: D
Rationale: The correct answer is D: Put the client in a side-lying position with the head of the bed lowered. This position helps prevent aspiration of fluids into the lungs by allowing gravity to assist in draining fluids out of the mouth and reducing the risk of them entering the airway. It also helps in preventing choking and aspiration pneumonia. A: Washing hands and observing infection control are important but do not directly address the risk of aspiration. B: Keeping the client dry with a towel does not specifically prevent aspiration and may not be effective in managing oral care for an unconscious client. C: Cleaning the mouth with oral swabs is important, but the technique does not directly address the risk of aspiration compared to positioning the client correctly.
Question 5 of 5
A nurse must verify the client's identity before administering medication. The safest way to verify identity is to:
Correct Answer: B
Rationale: The correct answer is B: Check the client's identification band. This method is the safest way to verify the client's identity because it directly links the client to a unique identification band that is specifically assigned to them. This ensures accuracy and minimizes the risk of error. A: Asking the client his name may not be reliable as the client could provide incorrect information. C: Stating the client's name aloud and having them repeat it relies on the client's memory and verbal confirmation, which may not be foolproof. D: Checking the room number and the client's name on the bed is not as direct and specific as checking the client's identification band, which could lead to confusion if there are multiple clients in the same room.