ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
In changing tracheostomy ties, the nurse should:
Correct Answer: C
Rationale: Rationale: Choice C is correct because it involves removing one side of the old tie before threading the clean tape through the eye of the flange. This method ensures that the tracheostomy remains secure while changing ties, reducing the risk of accidental decannulation or displacement. Removing both ties (Choice D) can compromise the patient's airway, while tying the new tie to the eye of the flange with old ties in place (Choice B) can lead to inadequate support. Choice A is incorrect because threading the clean tape through the eye of the flange before removing the old ties can result in instability and potential harm to the patient.
Question 2 of 5
A client who is scheduled for a bone marrow aspiration asks the nurse about the site that will be used for the procedure. The nurse tells the client that in addition to the iliac crest, the____ may be used.
Correct Answer: C
Rationale: The correct answer is C: Sternum. The sternum is another common site for bone marrow aspiration, along with the iliac crest. The sternum is easily accessible, especially in emergency situations. Aspiration from the sternum is less painful compared to the iliac crest. The femur (choice A) is not typically used for bone marrow aspiration due to the risk of injury to major blood vessels. The ribs (choice B) are not ideal due to the risk of pneumothorax. The scapula (choice D) is not commonly used due to limited accessibility and risk of injury to surrounding structures.
Question 3 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 4 of 5
A postoperative patient has ineffective airway clearance. Which data would indicate to the nurse that interventions for this patient problem have been successful?
Correct Answer: C
Rationale: The correct answer is C because clear breath sounds indicate effective airway clearance. Clear breath sounds suggest that air is flowing freely through the airways, indicating successful interventions. A: Fluid intake does not directly reflect airway clearance. B: Using a spirometer may improve lung function but does not necessarily indicate effective airway clearance. D: Temperature is not directly related to airway clearance.
Question 5 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.