ATI RN
Chapter 1 Introduction to Nursing Quizlet Questions
Question 1 of 5
In obtaining the cerebrospinal fluid, the needle is inserted:
Correct Answer: B
Rationale: The correct answer is B: Between L3 and L4. The cerebrospinal fluid is obtained via a procedure called lumbar puncture, commonly known as a spinal tap. The needle is inserted between the third and fourth lumbar vertebrae to avoid the spinal cord itself. This location provides access to the subarachnoid space where the cerebrospinal fluid circulates. Choosing A, C, or D would result in potential damage to the spinal cord or improper collection of cerebrospinal fluid.
Question 2 of 5
A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss?
Correct Answer: B
Rationale: The correct answer is B. Anxious clients with tachypnea are at greatest risk for insensible water loss due to increased respiratory rate leading to increased water evaporation from the lungs. This results in higher water loss compared to other options. Clients taking furosemide (A) may experience increased urine output but it is not considered insensible water loss. Clients on fluid restrictions (C) would have decreased water intake but it is not insensible loss. Constipated clients (D) may have fluid imbalance but it is not related to insensible water loss.
Question 3 of 5
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a band count of 11%. What prescribed action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Obtain cultures of the wound. With an elevated WBC count and high band count, there is a high suspicion of infection. Obtaining cultures will help identify the specific pathogen causing the infection and guide appropriate antibiotic therapy. This is crucial for effective treatment and preventing complications. Incorrect choices: B: Beginning antibiotic administration without knowing the specific pathogen may lead to inappropriate treatment. C: Continuing to monitor the wound for drainage does not address the underlying infection. D: Redressing the wound with wet-to-dry dressings does not address the need for identifying the specific pathogen causing the infection.
Question 4 of 5
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client’s teaching?
Correct Answer: B
Rationale: The correct answer is B: “Notify the clinic if you notice muscle twitching.” Muscle twitching can be a symptom of hyponatremia, which is a condition characterized by low sodium levels in the blood. The nurse should include this statement in the client’s teaching because it is important for the client to recognize and report this symptom promptly to prevent potential complications. Muscle twitching can indicate worsening hyponatremia and requires medical attention. Incorrect choices: A: “Have your spouse watch you for irritability and anxiety.” This choice focuses on emotional symptoms rather than physical symptoms of hyponatremia. C: “Call your primary health care provider for diarrhea.” Diarrhea is not a common symptom of hyponatremia; this choice is unrelated to the condition. D: “Bake or grill your meat rather than frying it.” This choice is unrelated to the prevention or management of hyponatremia.
Question 5 of 5
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism of the left lower leg. Which action by the nurse is best?
Correct Answer: D
Rationale: The correct answer is D because elevating the thighs and lower legs above the heart level promotes venous return and reduces swelling in the affected leg, aiding in the prevention of complications related to venous thromboembolism. Placing one pillow under the thighs and two pillows under the lower legs ensures proper elevation and support. A: Placing the bed in Trendelenburg position isn't appropriate as it involves the head being lower than the feet, which could increase pressure on the lower extremities and potentially worsen the condition. B: Placing two pillows under the calf of the affected leg doesn't provide sufficient elevation for optimal venous return and may not effectively reduce swelling. C: Elevating only at the knee and placing pillows under both feet may not adequately elevate the lower extremities above heart level, limiting the effectiveness of venous return and swelling reduction.