ATI RN
Introduction to Professional Nursing Quizlet Questions
Question 1 of 5
Nurse Fely is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. Which of the following assessment findings is the MOST ALARMING?
Correct Answer: A
Rationale: The correct answer is A: Temperature: 38.1 C. A fever is the most alarming finding as it indicates a potential systemic infection, especially in a client with a central line and redness at the insertion site. Fever can be a sign of sepsis which requires immediate intervention. Choice B: Expiration date is next month is not relevant to the current situation and does not indicate an immediate threat to the client's health. Choice C: Dressing change due today, while important for infection prevention, is not the most alarming finding in this scenario as it can be addressed promptly. Choice D: Tight tubing connections can lead to complications but are not as urgent or life-threatening as a fever in a client with a central line and redness at the site.
Question 2 of 5
A client has an order of small volume enema after an oral laxative fails to produce sufficient stool return. The nurse informs the client of the procedure. The client asks the nurse what small volume enema is all about. The nurse offered an APPROPRIATE answer when she states that small volume enema is:
Correct Answer: C
Rationale: The correct answer is C: Used to clean the sigmoid and rectum. Small volume enema is specifically designed to target the lower part of the colon, which includes the sigmoid colon and rectum. This type of enema is not meant to cleanse the entire colon like a large volume enema would. It is focused on providing relief and stimulation to the lower bowel to help with stool return. Explanation of incorrect choices: A: A laxative solution - Small volume enema is not just a laxative solution, it is a specific type of enema with a targeted purpose. B: Given to cleanse the colon - Small volume enema is not intended to cleanse the entire colon but rather the lower part. D: A commercially prepared enema - While small volume enemas can be commercially prepared, this choice does not address the specific purpose of the enema, which is to clean the sigmoid and rectum.
Question 3 of 5
During the planning step of the nursing process, the nurse performs which activity?
Correct Answer: B
Rationale: During the planning step of the nursing process, the nurse develops goals of care to address the patient's needs identified during data collection and analysis. This step involves setting specific, measurable, achievable, relevant, and time-bound objectives to guide the care provided. Developing goals of care ensures that the care plan is individualized, patient-centered, and focused on achieving positive outcomes for the patient. Recording data (A) is part of the assessment phase, collecting data (C) is part of the assessment phase, and carrying out interventions (D) is part of the implementation phase of the nursing process, not the planning phase.
Question 4 of 5
The nurse is assessing the client who has edema. The skin remains indented or pitted at 8mm. The nurse describes the degree of edema as:
Correct Answer: D
Rationale: The correct answer is D (4+). This degree of edema indicates severe pitting edema where the skin remains indented or pitted at 8mm. This level of indentation signifies a significant accumulation of fluid in the tissues. Choices A (1+), B (2+), and C (3+) represent varying degrees of pitting edema with shallower indentations ranging from 2mm to 6mm, which are considered mild to moderate levels of edema. Therefore, the correct assessment of 4+ reflects the severity of the client's condition based on the depth of indentation and the amount of accumulated fluid in the tissues.
Question 5 of 5
The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?
Correct Answer: C
Rationale: The correct answer is C (38.9° C) because to convert Fahrenheit to Celsius, you subtract 32 from the Fahrenheit temperature and then multiply by 5/9. So, 102°F - 32 = 70, and 70 x 5/9 = 38.9°C. Choice A (39°C) is close but not exact. Choice B (47°C) and D (40.1°C) are significantly off and do not follow the correct conversion formula.