ATI RN
Introduction to Nursing Quizlet Questions
Question 1 of 5
Mr. King is receiving heparin subcutaneously. Which of the following demonstrates correct technique for this procedure?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. Heparin is administered subcutaneously, not intramuscularly, so aspirating is not necessary. 2. Aspirating can cause bruising or bleeding due to the fragility of subcutaneous blood vessels. 3. Massaging after the injection can lead to hematoma formation. 4. By not aspirating before or massaging after the injection, the risk of complications is minimized. Summary: A: Incorrect - Aspirating can lead to complications, and massaging may cause hematoma. B: Incorrect - Massaging for one minute is excessive and can increase the risk of hematoma formation. D: Incorrect - Massaging the site can lead to bruising, and aspiration is unnecessary and potentially harmful.
Question 2 of 5
Which of the following is an appropriate nursing intervention for a client wearing anti-embolic stockings?
Correct Answer: A
Rationale: Correct Answer: A - Measure the legs before applying stockings to assure proper fit. Rationale: Proper fit is crucial for the effectiveness of anti-embolic stockings. Measuring the legs ensures a snug but not too tight fit, promoting circulation without causing discomfort or complications. This step helps prevent skin breakdown, nerve compression, and circulation issues. Summary of Incorrect Choices: B: Applying the stockings while the client is sitting in a chair - This is incorrect as stockings should be applied when the client is lying down with legs elevated to reduce swelling and make application easier. C: Massage the legs when removing the stockings - Massaging the legs can dislodge blood clots, which is dangerous for clients wearing anti-embolic stockings. D: Leave the stockings in place for one week intervals - Stockings should be regularly removed and washed to maintain hygiene and prevent skin irritation or infections. Leaving them on for a week can lead to complications.
Question 3 of 5
A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?
Correct Answer: B
Rationale: The correct answer is B: Increase your fluid intake to 2 to 3 L per day. This instruction is important after extracorporeal shock wave lithotripsy to help flush out the stone fragments and prevent urinary tract infections. Increasing fluid intake also helps prevent dehydration and promotes kidney function. A: Taking temperature every 4 hours is not necessary post-lithotripsy unless the client develops signs of infection. C: Applying an antibacterial dressing daily is not typically required after lithotripsy unless specifically instructed by the healthcare provider. D: Urine turning cherry red after lithotripsy is due to blood in the urine, which is expected, but this should resolve within 24-48 hours, not 5 to 7 days.
Question 4 of 5
The client is scheduled for an intravenous pyelograph (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation?
Correct Answer: C
Rationale: The correct answer is C: Checking the client's history for allergy to iodine. This is crucial for IVP as iodine contrast dye is used, and an allergic reaction can occur. It is important to identify any potential allergies beforehand to prevent a serious reaction during the test. A: Ensuring adequate fluid intake on the day of the test - While hydration is important, it is not the most critical factor in pretest preparation for IVP. B: Preparing the client for the possibility of bladder spasms during the test - While informing the client about possible discomfort is important, it is not as essential as identifying allergies to iodine. D: Determining when the client last had a bowel movement - Bowel movement history is not directly related to the IVP procedure and is not as critical as checking for iodine allergy.
Question 5 of 5
A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first?
Correct Answer: D
Rationale: The correct answer is D because assessing the right leg for pulses, skin color, and temperature is the priority to determine the perfusion status and tissue viability. This step is crucial in identifying any vascular compromise that could be contributing to the nonhealing pressure injury. Drawing blood for albumin, prealbumin, and total protein (A) can provide information on the client's nutritional status but is not the immediate priority. Preparing for a wound culture (B) is important for determining the presence of infection but should come after assessing perfusion. Instructing the client to elevate the foot (C) can help with reducing edema but is not the first action when dealing with a nonhealing pressure injury.