ATI RN
Introduction to Nursing Questions
Question 1 of 5
Organize the following steps to suctioning in chronological order: 1) Put on sterile glove 2) Lubricate catheter with normal saline 3) Apply suction for 5-10 seconds 4) Explain procedure to client 5) Wash hands thoroughly
Correct Answer: A
Rationale: The correct order is 45123. 1. "Put on sterile glove" (Step 4) is the first step to maintain aseptic technique. 2. "Explain procedure to client" (Step 5) should be done before any intervention for informed consent. 3. "Lubricate catheter with normal saline" (Step 2) prepares the catheter for insertion. 4. "Apply suction for 5-10 seconds" (Step 1) is done after catheter insertion. 5. "Wash hands thoroughly" (Step 3) is the final step to prevent cross-contamination. Other choices are incorrect because they do not follow the correct sequence of aseptic technique and patient safety measures.
Question 2 of 5
Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?
Correct Answer: C
Rationale: The correct answer is C: Have the client expectorate the sputum into a sterile container. This is the correct procedure because using a sterile container ensures that the specimen remains uncontaminated for accurate culture and sensitivity testing. Choice A is incorrect as placing the specimen in a non-sterile container and enclosing it in a plastic bag can introduce contaminants. Choice B is incorrect as the nurse should not hold the container with bare hands to prevent contamination. Choice D is incorrect as offering an antiseptic mouthwash can alter the microbial flora in the sputum, affecting test results.
Question 3 of 5
A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Perform a bladder scan. The first step is to assess the patient's bladder volume non-invasively before considering invasive procedures like catheterization. A bladder scan will provide information about the patient's bladder volume and guide further interventions. Choice B (Insert a straight catheter) is incorrect as this is an invasive procedure and should not be the first action without assessing the bladder volume. Choice C (Encourage increased oral fluid intake) is incorrect as it does not address the immediate need to assess the patient's bladder status. Choice D (Assist the patient to ambulate to the bathroom) is incorrect as this may not resolve the issue if the patient has bladder retention.
Question 4 of 5
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
Correct Answer: A
Rationale: The correct answer is A: Assess the client for anxiety. The client's lack of comprehension, forgetfulness, and repetitive questioning are indicative of potential anxiety affecting their ability to process information. By assessing for anxiety, the nurse can address the underlying issue and provide appropriate support. Breaking information into smaller bits (B) may help but doesn't address the root cause. Giving written information (C) may not be effective if the client is experiencing anxiety. Simply reviewing the information again (D) without addressing the anxiety may not improve the client's understanding.
Question 5 of 5
A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound?
Correct Answer: D
Rationale: The correct answer is D: Multi-fiber superabsorbent dressing. This type of dressing is ideal for a wound with copious exudate as it can effectively absorb and contain the excessive fluid. It helps maintain a moist wound environment conducive to healing while preventing maceration. Wet-to-damp gauze (A) can cause trauma upon removal. Leaving the wound open (B) increases the risk of infection. Transparent film (C) may not provide enough absorbency for a wound with high exudate.