ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
The emergency department nurse is evaluating the outcomes for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?
Correct Answer: A
Rationale: The correct answer is A: 02 saturation is >90%. This is the best indicator because it directly measures the amount of oxygen in the blood, reflecting the effectiveness of the treatment in improving ventilation and oxygenation. - Choice B: No wheezes are audible. Wheezes can persist even after treatment, so absence of wheezes does not always indicate effectiveness. - Choice C: Respiratory rate is 16 breaths/min. While a normal respiratory rate is a good sign, it may not necessarily indicate the full effectiveness of the treatment. - Choice D: Accessory muscle use has decreased. Although a decrease in accessory muscle use is positive, it may not always correlate directly with improved oxygenation and ventilation.
Question 2 of 5
The client, returning from a coronary catheterization in which the femoral artery approach was used, sneezes. Which should be the nurse's priority intervention?
Correct Answer: D
Rationale: The correct answer is D: Check the insertion site. This is the priority intervention because sneezing can increase pressure in the femoral artery, potentially causing bleeding or dislodging the catheter. Checking the insertion site allows the nurse to assess for any signs of bleeding, hematoma, or catheter migration. Palpating pedal pulses (choice A) may be important but not as immediate as ensuring catheter site integrity. Measuring vital signs (choice B) is important but not the priority in this scenario. Assessing for urticaria (choice C) is not relevant to the immediate risk associated with sneezing post-catheterization.
Question 3 of 5
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?
Correct Answer: B
Rationale: Step 1: Documenting the assessment is appropriate as redness and warmth around the incision on the first postoperative day are common signs of normal inflammation. Step 2: This action allows for tracking changes in the wound over time. Step 3: It provides a baseline for comparison in case the condition worsens. Step 4: Obtaining wound cultures (A) is premature as it is not indicated for initial signs of inflammation. Step 5: Notifying the health care provider (C) may be necessary if the condition worsens, but it is not the first step. Step 6: Assessing the wound every 2 hours (D) is excessive and unnecessary unless there are other concerning symptoms.
Question 4 of 5
A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find?
Correct Answer: D
Rationale: The correct answer is D because beta blockers lower heart rate by blocking the effects of adrenaline on the heart. This results in a decreased pulse rate. Choice A is incorrect because beta blockers typically lower blood pressure. Choice B is incorrect as beta blockers do not directly affect respiratory rate. Choice C is incorrect because beta blockers do not affect oxygen saturation directly. Overall, the expected assessment after administering a beta blocker would be a decrease in heart rate (pulse).
Question 5 of 5
The client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which of the following documented in the client's record is an expected finding with this client?
Correct Answer: B
Rationale: The correct answer is B: Hyperinflation of lungs documented by chest x-ray. In COPD exacerbation, the airways become inflamed and narrowed, leading to air trapping and hyperinflation of the lungs. This is evidenced on chest x-ray by increased lung volume and flattened diaphragms due to overinflation. Choices A, C, and D are incorrect because in COPD exacerbation, oxygen saturation typically decreases with ambulation due to impaired gas exchange, a widened diaphragm is not a typical finding on chest x-ray in COPD exacerbation, and a shortened expiratory phase is more commonly seen in obstructive lung diseases like asthma rather than COPD exacerbation.