ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
Raymond is a 5-year-old with chronic disease. He had just undergone insertion of central venous catheter via ultrasound. Which of the assessment data should you look first prior to administration of IV fluids?
Correct Answer: D
Rationale: The correct answer is D: Chest radiology results. This is the most critical assessment data to look at first before administering IV fluids to Raymond. By checking the chest radiology results, we can ensure that the central venous catheter is properly placed without any complications such as pneumothorax or malposition. This step is crucial for safe IV fluid administration. A: Serum osmolality and B: Serum electrolyte levels are important assessments but are not as immediate as checking the catheter placement. C: Intake and output record is important for monitoring fluid balance but does not take precedence over confirming the catheter placement.
Question 2 of 5
In intravenous therapy, the rule is to use veins of the upper extremities first. The superficial veins of the dorsal aspect of the hand are the preferred site. Which area of the wrist is highly sensitive and most painful site of venipuncture and must be avoided by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Inner aspect. This area of the wrist has a higher concentration of nerve endings, making it more sensitive and prone to causing more pain during venipuncture. It is essential for the nurse to avoid this area to prevent unnecessary discomfort and ensure successful venipuncture. The other choices (A: Outer aspect, B: Upper aspect, and C: Lower aspect) do not have the same high sensitivity and pain potential as the inner aspect, making them less critical to avoid during venipuncture.
Question 3 of 5
A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. The client remaining free of signs and symptoms of phlebitis indicates that the I.V. site is not infected or inflamed, ensuring proper infusion. 2. Phlebitis can lead to complications such as infection and thrombosis if not managed promptly. 3. Monitoring for phlebitis is crucial to prevent further complications and ensure the client's safety. 4. Options A, C, and D do not directly address the expected outcome of maintaining the client free of phlebitis symptoms.
Question 4 of 5
When percussing a client's chest, the nurse should identify which sound as a normal finding?
Correct Answer: C
Rationale: The correct answer is C: Resonance. When percussing the chest, resonance is the normal sound produced over healthy lung tissue. It indicates air-filled lungs. Hyperresonance (A) is an abnormal sound found in conditions like emphysema. Tympany (B) is a drum-like sound heard over air-filled areas like the stomach. Dullness (D) is heard over solid organs or areas with fluid accumulation, indicating abnormal findings. In summary, resonance is the expected sound over healthy lung tissue, making it the correct choice.
Question 5 of 5
In assessing oral temperature, how long should the nurse wait prior to reading the thermometer?
Correct Answer: C
Rationale: The correct answer is C (2-3 minutes). After placing the oral thermometer under the tongue, waiting for 2-3 minutes allows for an accurate reading of the oral temperature to be obtained. This timeframe ensures that the thermometer has enough time to accurately measure the body temperature. A (30 seconds) is too short for an accurate reading as it may not provide enough time for the thermometer to stabilize. B (1 full minute) is also not sufficient for an accurate reading. D (10 minutes) is too long and unnecessary, as it can lead to discomfort for the patient and does not improve the accuracy of the reading.