ATI RN
Introduction to Nursing Questions
Question 1 of 5
Nurse Corazon is making initial rounds at the beginning of the shift. She enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the bag is empty. Which of the following solutions readily available on the nursing unit should the she hang until another TPN solution is mixed and delivered to the nursing unit?
Correct Answer: B
Rationale: The correct answer is B: 5% dextrose in water. When a TPN bag is empty, it is important to prevent hypoglycemia by providing a temporary source of glucose until a new TPN solution can be prepared. 5% dextrose in water is the appropriate choice as it provides a low concentration of glucose to maintain blood sugar levels without overloading the patient with excessive dextrose. Option A, 10% dextrose in water, is too concentrated and may cause hyperglycemia in the patient. Option C, 5% dextrose in 0.9% sodium chloride, is not ideal as the patient on TPN does not need additional sodium and chloride in the solution. Option D, None of the above, is incorrect as providing no solution would leave the patient at risk of hypoglycemia.
Question 2 of 5
Which nursing diagnosis would comply with guidelines set forth by NANDA?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury related to generalized weakness. This diagnosis complies with NANDA guidelines as it is specific, measurable, and based on clinical judgment. It focuses on the potential harm a patient may experience due to their weakness, aligning with NANDA's criteria for nursing diagnoses. The other choices lack specificity and do not directly address the patient's actual health problem. Choice A assumes the cause of ineffective airway clearance without assessment data. Choice B involves psychological factors not directly related to a physiological condition. Choice C implies a behavioral issue rather than a potential health risk.
Question 3 of 5
A client's wound is draining thick yellow material. The nurse correctly describes the drainage as:
Correct Answer: D
Rationale: The correct answer is D: Purulent. This is because thick yellow drainage indicates the presence of pus, which is characteristic of purulent drainage. Pus consists of dead white blood cells, tissue debris, and bacteria, signifying infection. Sanguineous drainage is fresh red blood, serous-sanguineous is a mix of clear and red drainage, and serous is clear and watery. Therefore, in this case, purulent is the most appropriate description of the drainage.
Question 4 of 5
After a few hours in the emergency room, the client is admitted to the ward with an order of hourly monitoring of BP. The nurse finds that the cuff is too narrow and this will cause the BP reading to be:
Correct Answer: B
Rationale: The correct answer is B: Higher than what the reading should be. A narrow cuff will result in inaccurate BP readings because it can cause increased pressure on the artery, leading to artificially elevated readings. When the cuff is too narrow, it can compress the artery more than necessary, resulting in a higher BP reading. This is why it is important to use the correct cuff size based on the client's arm circumference to obtain an accurate reading. Choices A and C are incorrect because a narrow cuff would not result in a lower or the same BP reading, respectively. Choice D, inconsistent, is also incorrect because the incorrect cuff size will consistently produce higher readings due to increased pressure on the artery.
Question 5 of 5
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following assessments is appropriate for the nurse to perform?
Correct Answer: B
Rationale: The correct answer is B: Auscultate the mass. Auscultation can help identify the nature of the pulsating mass, such as detecting bruits, which may indicate an underlying vascular issue. Measuring the length (A) is not relevant for assessing a pulsating mass. Percussion (C) is used to assess underlying structures, not the nature of a mass. Palpation (D) can provide information on the size, shape, and consistency of the mass but auscultation is essential to detect potential abnormalities like bruits.