ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
In intravenous therapy, the rule is to use veins of the upper extremities first. The superficial veins of the dorsal aspect of the hand are the preferred site. Which area of the wrist is highly sensitive and most painful site of venipuncture and must be avoided by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Inner aspect. This area of the wrist has a higher concentration of nerve endings, making it more sensitive and prone to causing more pain during venipuncture. It is essential for the nurse to avoid this area to prevent unnecessary discomfort and ensure successful venipuncture. The other choices (A: Outer aspect, B: Upper aspect, and C: Lower aspect) do not have the same high sensitivity and pain potential as the inner aspect, making them less critical to avoid during venipuncture.
Question 2 of 5
When percussing a client's chest, the nurse should identify which sound as a normal finding?
Correct Answer: C
Rationale: The correct answer is C: Resonance. When percussing the chest, resonance is the normal sound produced over healthy lung tissue. It indicates air-filled lungs. Hyperresonance (A) is an abnormal sound found in conditions like emphysema. Tympany (B) is a drum-like sound heard over air-filled areas like the stomach. Dullness (D) is heard over solid organs or areas with fluid accumulation, indicating abnormal findings. In summary, resonance is the expected sound over healthy lung tissue, making it the correct choice.
Question 3 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 4 of 5
What type of fever would the nurse document if the client had a wide range of temperature fluctuations over normal for a period of 24 hours?
Correct Answer: B
Rationale: The correct answer is B: Remittent fever. Remittent fever is characterized by wide temperature fluctuations over normal within a 24-hour period, without returning to normal in between. Intermittent fever has periods of normal temperature between spikes. Relapsing fever has recurring episodes of fevers with symptom-free intervals. Constant fever remains consistently elevated without fluctuations. Therefore, the correct choice is B as it aligns with the described temperature pattern.
Question 5 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.