ATI RN
Introduction to Nursing Final Exam Quizlet Questions
Question 1 of 5
Taking the temperature rectally is contraindicated with which of the following clients?
Correct Answer: B
Rationale: The correct answer is B: A client with significant hemorrhoids. Rectal temperature measurement is contraindicated in clients with significant hemorrhoids due to the risk of causing discomfort, pain, and potential bleeding. It can worsen the condition and lead to complications. A: A client who had adenoidectomy - This does not directly affect the rectal temperature measurement process. C: A client who smokes - Smoking does not specifically contraindicate rectal temperature measurement. D: A client with wired jaws - This does not impact the rectal temperature measurement process.
Question 2 of 5
Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?
Correct Answer: D
Rationale: The correct answer is D because whitish oval specks sticking to the hair are nits, which are eggs of head lice, confirming pediculosis capitis. Nits are firmly attached to the hair shaft close to the scalp. A: Scratching the head more than usual can be a symptom but not confirmatory. B: Flakes on shoulders could be dandruff. C: Oval pattern occipital hair loss is not specific to head lice.
Question 3 of 5
Nurse De Silva knows he can perform chest physiotherapy:
Correct Answer: B
Rationale: Correct Answer: B (One hour after meals) Rationale: Performing chest physiotherapy one hour after meals helps prevent aspiration during the procedure. Waiting allows food to move from the stomach to the small intestine, reducing the risk of aspiration. Performing chest physiotherapy immediately before meals (A) or during meals (C) could increase the risk of aspiration. Similarly, performing it before bedtime (D) may also increase the risk of aspiration as the patient lies down after the procedure.
Question 4 of 5
A client is admitted to the Emergency Department after a motorcycle accident that resulted in the client's skidding across a cement parking lot. Since the client was wearing shorts, there are large areas on the legs where the skin is ripped off. This wound is best described as:
Correct Answer: A
Rationale: The correct answer is A: Abrasion. An abrasion is a wound caused by friction, resulting in the removal of the superficial layers of skin. In this scenario, the client skidding across a cement parking lot caused the skin to be ripped off, which aligns with the definition of an abrasion. Choice B: Unapproximated, is incorrect because it refers to wound edges that are not brought together for healing, which is not the primary characteristic of the described wound. Choice C: Laceration, is incorrect as lacerations are typically caused by sharp objects cutting through the skin, rather than by friction as in the case of the motorcycle accident. Choice D: Eschar, is incorrect as eschar refers to a thick, hard, blackened crust that forms over a burn or necrotic tissue, which is not the case in this scenario.
Question 5 of 5
To give a Z-track injection, the nurse measures the correct medication dose and then draws a small amount of air into the syringe. What is the rationale for this action?
Correct Answer: B
Rationale: The correct answer is B: Adding air prevents the drug from flowing back into the needle track. When giving a Z-track injection, the nurse pulls the skin to the side before inserting the needle. By adding air into the syringe after drawing up the medication, a small air bubble is created above the medication in the syringe. This air bubble creates a seal when the needle is withdrawn, preventing the medication from leaking back into the needle track and causing irritation or staining. Incorrect choices: A: Adding air does not decrease pain caused by the injection. C: Adding air does not prevent the solution from entering a blood vessel. D: Adding air does not ensure that the client receives the entire dose.