ATI RN
Introduction to Nursing Final Exam Quizlet Questions
Question 1 of 5
Mrs. Sales also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?
Correct Answer: C
Rationale: The correct answer is C: Loss of tone of the smooth muscles of the colon. As individuals age, the smooth muscles of the colon can lose their tone, resulting in slower peristalsis and decreased bowel movements, leading to constipation. This physical change is a common factor contributing to constipation in older adults. A: Inhibition of the parasympathetic reflex is not directly related to constipation in aging individuals. Parasympathetic stimulation usually promotes bowel movements. B: Esophageal emptying hastening is not relevant to constipation. Esophageal emptying refers to the movement of food from the esophagus into the stomach, not the colon. D: Decreased ability to absorb fluids in the lower intestines is not a typical physical change associated with aging that predisposes individuals to constipation. Constipation is more commonly linked to issues with colonic motility rather than fluid absorption.
Question 2 of 5
When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be:
Correct Answer: C
Rationale: The correct answer is C: Administering pain medication. In Maslow's hierarchy of needs, physiological needs like pain relief are the most basic and must be addressed first for the client's well-being. Administering pain medication ensures the client's physical comfort and safety, which is crucial before addressing other needs. Allowing the family to see the client (A) and ambulating the client (B) are important but not as urgent as addressing pain. Placing wrist restraints on the client (D) should only be considered if absolutely necessary for the client's safety and should not be the first priority.
Question 3 of 5
When auscultating a client's chest, the nurse assesses a second heart sound (S2). This sound results from:
Correct Answer: D
Rationale: The second heart sound (S2) occurs during the closing of the aortic and pulmonic valves. This closure marks the end of systole and the beginning of diastole. The closure of these valves produces a characteristic "dub" sound. The opening of the mitral and tricuspid valves occurs during diastole, while the opening of the aortic and pulmonic valves happens during systole. Therefore, the correct answer is D, as it accurately reflects the physiological basis of S2. The other choices (A, B, C) are incorrect as they do not align with the specific cardiac events associated with the second heart sound.
Question 4 of 5
Taking the temperature rectally is contraindicated with which of the following clients?
Correct Answer: B
Rationale: The correct answer is B: A client with significant hemorrhoids. Rectal temperature measurement is contraindicated in clients with significant hemorrhoids due to the risk of causing discomfort, pain, and potential bleeding. It can worsen the condition and lead to complications. A: A client who had adenoidectomy - This does not directly affect the rectal temperature measurement process. C: A client who smokes - Smoking does not specifically contraindicate rectal temperature measurement. D: A client with wired jaws - This does not impact the rectal temperature measurement process.
Question 5 of 5
Which of the following is a priority nursing action when administering oral care to a dependent client?
Correct Answer: B
Rationale: The correct answer is B: Wear disposable gloves. This is a priority nursing action to prevent the spread of infection and protect both the client and the caregiver. By wearing disposable gloves, the nurse maintains proper infection control practices and reduces the risk of transmitting pathogens during oral care procedures. A: Assisting the client to a dorsal recumbent position is not specifically related to oral care and is not a priority action. C: Using a firm toothbrush may cause injury to the client's gums and oral tissues, so it is not the best choice for oral care. D: Irrigating the mouth with hydrogen peroxide is not a recommended practice for routine oral care, as it can be harmful if ingested and may cause irritation to the oral mucosa.