ATI RN
Introduction to Professional Nursing Quizlet Questions
Question 1 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: The correct answer is B: Document the assessment. This is appropriate because redness and warmth around the incision on the first postoperative day are common signs of normal inflammatory response. Documenting the assessment allows for accurate tracking of the wound's progression. Obtaining wound cultures (choice A) is not necessary at this stage as it's too early to indicate infection. Notifying the health care provider (choice C) may be premature and can cause unnecessary alarm. Assessing the wound every 2 hours (choice D) is excessive and not indicated unless there are other concerning symptoms.
Question 2 of 5
The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Avoid giving IM medications to prevent localized bleeding. When a patient is on heparin therapy with PTT monitoring, it is crucial to avoid IM injections to prevent localized bleeding due to the anticoagulant effects of heparin. IM injections can lead to hematomas and increased bleeding risk. Monitoring for bilateral pedal pulses (A) is important for assessing circulation but not directly related to heparin therapy. Decreasing the infusion when PTT is 65 seconds (B) is not appropriate as the therapeutic range for PTT varies depending on the patient's condition. Having vitamin K available (D) is not necessary for heparin reversal as vitamin K does not reverse the effects of heparin.
Question 3 of 5
Heparin is ordered for a patient with a non–ST-segment- elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient?
Correct Answer: C
Rationale: Step 1: Heparin is an anticoagulant medication that works by preventing the formation of new blood clots. Step 2: In NSTEMI, there is a risk of developing new clots in the coronary arteries, which can worsen the condition. Step 3: By explaining that heparin prevents the development of new clots, the nurse helps the patient understand the purpose of the medication in preventing further complications. Step 4: Option C is correct as it directly addresses the mechanism of action of heparin in NSTEMI. Step 5: Incorrect choices: A: Incorrect, as heparin does not enhance platelet aggregation but rather inhibits clot formation. B: Incorrect, as heparin does not decrease the size of coronary artery plaque. D: Incorrect, as heparin does not dissolve existing clots but prevents new clot formation.
Question 4 of 5
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?
Correct Answer: C
Rationale: The correct action is to medicate the patient with prescribed morphine first. The patient is experiencing incisional pain, poor cough effort, and coarse crackles, indicating possible atelectasis or pneumonia post-thoracotomy. Morphine will help relieve the pain, improve cough effort, and decrease anxiety associated with breathing difficulties. It is essential to address pain and discomfort to facilitate effective coughing and deep breathing exercises, promoting optimal lung expansion and preventing respiratory complications. Sitting upright, splinting the chest, or using the incentive spirometer are important interventions but addressing the pain is the priority in this situation.
Question 5 of 5
The nurse analyzes the results of a patient’s arterial blood gases (ABGs). Which finding requires immediate action?
Correct Answer: D
Rationale: The correct answer is D because a PaO2 level of 62 mm Hg indicates severe hypoxemia, which is a critical condition requiring immediate action to prevent tissue damage and organ failure. Normal PaO2 levels are around 80-100 mm Hg. A low PaO2 indicates poor oxygenation of the blood. Choice A (HCO3?2-) being slightly elevated is not an emergency but may indicate metabolic alkalosis. Choice B (SaO2) at 92% is within the normal range for most patients. Choice C (PaCO2) at 31 mm Hg is also within normal limits and suggests adequate ventilation. In summary, a low PaO2 level is the most critical finding that requires immediate intervention compared to the other choices.