ATI RN
Basic Nursing Care of the Patient Questions
Question 1 of 5
Ms. Kelly. has had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects correct use of the cane?
Correct Answer: A
Rationale: When a client with weakness on one side uses a cane, there should always be two points of contact with the floor. When Ms. Kelly moves the cane forward, she has both feet on the floor, providing stability. As she moves the weak leg, the cane and the strong leg provide support. Finally, the cane, which is now even with the weak leg, provides stability while she moves the strong leg. She should not hold the cane with her weak arm. The use of the cane requires arm strength to ensure that there is adequate stability when standing on the weak leg.
Question 2 of 5
The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure?
Correct Answer: D
Rationale: The correct answer is D: Emergency. This classification is based on the sudden and life-threatening nature of the situation, requiring immediate action to prevent harm to the patient. Profuse bleeding and the need for urgent return to the operating room indicate that this is an emergency procedure. Choices A, B, and C are incorrect because while the situation may be major, urgent, or elective in other contexts, in this case, the acuity of the situation necessitates an emergency classification to prioritize the patient's safety and well-being.
Question 3 of 5
The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the intraoperative phase?
Correct Answer: A
Rationale: The correct answer is A because being free of burns at the grounding pad is crucial for patient safety during surgery. If burns occur, it can lead to serious complications. Choices B, C, and D are important outcomes as well, but they are not as critical as preventing burns during the intraoperative phase. Nausea, vomiting, infection, and pain can be managed postoperatively, but preventing burns is a priority during the surgery itself.
Question 4 of 5
A patient in cardiac arrest is being resuscitated. You identify ventricular fibrillation on the cardiac monitor. CPR is ongoing. What is the next immediate intervention?
Correct Answer: B
Rationale: The correct next immediate intervention is to perform a defibrillation shock (Choice B) when ventricular fibrillation is identified in a patient in cardiac arrest. Defibrillation is crucial in restoring the heart's normal rhythm by delivering an electrical shock to the heart. This is a time-sensitive intervention that can increase the chance of successful resuscitation. Administering epinephrine (Choice A) helps support circulation but does not address the underlying arrhythmia. Establishing an advanced airway (Choice C) is important but is not the immediate priority when the patient is in ventricular fibrillation. Administering amiodarone (Choice D) is indicated after the first shock if the rhythm persists, but the initial priority in ventricular fibrillation is defibrillation.
Question 5 of 5
You are assessing a patient with an altered mental status and has a diabetic history. Which of the following would most likely indicate the patient is suffering from diabetic ketoacidosis?
Correct Answer: D
Rationale: The correct answer is D because the patient with diabetic ketoacidosis typically presents with dehydration, which is indicated by dry skin and mucous membranes. The increased thirst and frequent urination reported by family members are classic symptoms of uncontrolled diabetes leading to DKA. Hypotension and shallow rapid respirations are also common in DKA due to the metabolic acidosis. Choices A, B, and C are incorrect because they do not align with the typical presentation of diabetic ketoacidosis. Choice A describes a patient with hypoglycemia. Choice B describes a patient with septic shock. Choice C describes a patient with hypothermia. Therefore, based on the symptoms described and the patient's diabetic history, choice D is the most likely indication of diabetic ketoacidosis.