ATI RN
Introduction to Nursing Final Exam Quizlet Questions
Question 1 of 5
The client has just had a liver biopsy. Which of the following nursing actions would be the priority after the biopsy?
Correct Answer: A
Rationale: The correct answer is A because after a liver biopsy, the priority is to position the patient on the right side to apply pressure and prevent bleeding from the biopsy site on the liver's right lobe. This position helps compress the liver against the diaphragm, reducing the risk of bleeding. Choice B is incorrect as monitoring vital signs is important, but positioning the patient takes precedence immediately post-biopsy. Choice C is incorrect as ambulation may increase the risk of bleeding and should be avoided initially. Choice D is incorrect as measuring urine specific gravity is not directly related to post-liver biopsy care.
Question 2 of 5
A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select the one that does not apply.)
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Administering antibiotics for 72 hours is not within the nurse's scope of practice but the physician's responsibility. 2. Disposing of dressings properly prevents contamination and infection. 3. Leaving draining wounds open to air can introduce pathogens and hinder healing. 4. Performing proper hand hygiene reduces the transfer of pathogens to the wound site.
Question 3 of 5
A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for postdischarge care?
Correct Answer: C
Rationale: The correct answer is C because the older adult living alone with memory loss may be at higher risk for safety concerns and medication management post-discharge. Consulting other healthcare team members can ensure appropriate support services are in place. Choice A: While being a primary caregiver is important, it does not necessarily indicate a greater need for consultation compared to the other choices. Choice B: Post-knee replacement and needing physical therapy are common needs post-discharge, and consultation with the healthcare team may not be as critical as in the case of the older adult with memory loss. Choice D: Having family and friends nearby suggests a support system, reducing the immediate need for consultation compared to the older adult living alone with memory loss.
Question 4 of 5
The nurse should plan to use a wet-to-dry dressing for which patient?
Correct Answer: D
Rationale: Correct Answer: D Rationale: Wet-to-dry dressing is used for wounds with purulent drainage to promote healing by mechanical debridement. Purulent drainage indicates infection, making it necessary to remove dead tissue. Dry brown areas suggest necrosis, which requires removal to allow healthy tissue regeneration. Wet-to-dry dressing helps in this process by moistening the wound, facilitating the removal of necrotic tissue with each dressing change. This promotes a clean wound bed conducive to healing. Summary of Other Choices: A: Pink granulation tissue indicates healing, not requiring mechanical debridement. B: Surgical incision with pink, approximated edges indicates a well-healing wound, not requiring wet-to-dry dressing. C: Full-thickness burn with dry, black material suggests eschar formation, which requires specialized burn care, not wet-to-dry dressing.
Question 5 of 5
A patient has had recent mechanical heart valve surgery and is receiving anticoagulant therapy. While monitoring the patient‘s laboratory work, the nurse interprets that the patient‘s international normalized ratio (INR) level of 3 indicates that:
Correct Answer: B
Rationale: The correct answer is B: the patient's warfarin dose is at therapeutic levels. An INR level of 3 indicates the patient's blood is anticoagulated within the therapeutic range for mechanical heart valve surgery. This level helps prevent blood clots while minimizing the risk of bleeding. Choices A, C, and D are incorrect because an INR of 3 is not too low for warfarin therapy, not indicative of dangerously high heparin dose, and not related to heparin therapy. Overall, an INR of 3 is within the desired range for anticoagulation therapy post mechanical heart valve surgery.