ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
Nurse Jasmine provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?
Correct Answer: B
Rationale: The correct answer is B: "I need to restrict my activity while this catheter is in place." This statement is incorrect because clients with a PICC line do not need to restrict their activity. They can resume normal activities as tolerated unless otherwise instructed by their healthcare provider. Restricting activity unnecessarily can lead to deconditioning and reduced quality of life. A: "I need to wear a MedicAlert tag or bracelet." - This is a correct statement as it helps alert healthcare providers about the presence of the PICC line in case of an emergency. C: "I need to keep the insertion site protected when in the shower or bath." - This is a correct statement to prevent infection and maintain the integrity of the PICC line. D: "I need to check the markings on the catheter each time the dressing is changed." - This is a correct statement as it helps ensure the catheter is in the correct position.
Question 2 of 5
A client with a chest tube attached to a Pleurevac drainage system wants to get out of bed. While the nurse is assisting the client, the chest tubing accidentally gets caught in the bed rail and disconnects and the Pleur-Evac drainage system falls over and cracks. The nurse takes which immediate action?
Correct Answer: C
Rationale: The correct immediate action is to immerse the chest tube in a bottle of sterile normal saline. This is because it helps to maintain the sterility of the system and prevents air from entering the pleural space, thus avoiding a potential pneumothorax. Clamping the chest tube (choice A) can lead to tension pneumothorax. Applying petroleum gauze over the end of the chest tube (choice B) does not address the issue of maintaining sterility or preventing air leaks. Calling the physician (choice D) is not the immediate action needed to address the disconnection and potential contamination of the chest tube system.
Question 3 of 5
A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
Correct Answer: D
Rationale: The correct answer is D, Ineffective peripheral tissue perfusion related to venous congestion. Priority should be given to this nursing diagnosis because deep vein thrombosis can lead to impaired blood flow, potentially causing tissue ischemia and necrosis. Addressing ineffective tissue perfusion is crucial to prevent further complications such as tissue damage or even loss. Option A is incorrect as gas exchange is not the immediate concern in deep vein thrombosis. Option B is not directly related to the primary issue of venous congestion. Option C, risk for injury related to edema, is important but not as critical as ensuring adequate tissue perfusion to prevent further complications.
Question 4 of 5
During the physical examination, the nurse uses various techniques to assess structures, organs, and body systems. Which technique allows the nurse to feel for vibration and locate body structures?
Correct Answer: C
Rationale: The correct answer is C: Palpation. Palpation involves using hands to feel for vibration and locate body structures. This technique allows the nurse to assess for tenderness, texture, temperature, and size of organs or structures. Auscultation (A) involves listening for sounds using a stethoscope, not feeling. Inspection (B) involves visual examination, not tactile assessment. Percussion (D) involves tapping the body to listen for sounds, not feeling for vibration or locating structures. Palpation is the most appropriate technique for this purpose.
Question 5 of 5
Through the client’s history, you gather that the patient smokes and drinks coffee. When taking the temperature of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s oral temperature for accurate reading?
Correct Answer: C
Rationale: The correct answer is C: 30 minutes. After smoking or drinking coffee, the client's oral temperature can be affected by the hot or cold temperature of the substances ingested. Waiting for 30 minutes allows the client's oral cavity to return to its normal temperature, ensuring an accurate reading. Choices A, B, and D are incorrect because: A: 5 minutes is too short of a time for the oral cavity to adjust to the temperature changes caused by smoking or drinking coffee. B: 15 minutes may not be sufficient for the oral cavity to stabilize, leading to a potential inaccurate reading. D: 1 hour is too long of a wait time as the oral cavity typically stabilizes within 30 minutes after smoking or drinking coffee.