ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?
Correct Answer: B
Rationale: The correct answer is B because a swollen and warm calf could indicate deep vein thrombosis (DVT), a serious postoperative complication. DVT can lead to pulmonary embolism, which is life-threatening. Communicating this finding promptly allows for prompt evaluation and treatment. A: Elevated temperature is common postoperatively and may indicate infection, but DVT is more urgent. C: Abdominal pain when ambulating is expected post-hysterectomy and usually resolves with rest. D: Fluid intake greater than output may indicate a fluid imbalance, but DVT is a more concerning issue.
Question 2 of 5
An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?
Correct Answer: C
Rationale: The correct answer is C because positioning an unconscious patient on the side in the PACU helps prevent aspiration and ensures proper airway management. This position also promotes optimal ventilation and prevents airway obstruction. Choice A is incorrect because assisting a nauseated patient to a supine position can increase the risk of aspiration. Choice B is incorrect because placing a sleeping patient supine with the head elevated does not address airway protection for an unconscious patient. Choice D is incorrect as placing a patient in Trendelenburg position for low blood pressure is not recommended without a specific indication and can increase intracranial pressure in some cases.
Question 3 of 5
A patient who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive which antidote?
Correct Answer: B
Rationale: The correct antidote for a patient who has taken too much warfarin is Vitamin K. Warfarin inhibits Vitamin K-dependent clotting factors, leading to bleeding. Vitamin K helps restore these clotting factors. Vitamin E does not reverse warfarin's effects. Protamine sulfate is an antidote for heparin, not warfarin. Potassium chloride is used for treating low potassium levels, not warfarin toxicity. In summary, Vitamin K is the correct antidote for warfarin toxicity due to its role in restoring Vitamin K-dependent clotting factors, while the other choices are not indicated for this specific situation.
Question 4 of 5
While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient’s bed elevated 45 degrees. What does this finding indicate?
Correct Answer: C
Rationale: Step 1: Jugular venous distention (JVD) is often indicative of increased pressure in the right atrium. Step 2: Elevating the head of the bed to 45 degrees helps accentuate JVD, making it easier to observe. Step 3: Increased right atrial pressure can be caused by conditions like heart failure or tricuspid valve regurgitation. Step 4: This finding is significant in older adults as they are more prone to cardiovascular issues. Summary: Choice A is incorrect as JVD typically indicates fluid overload, not decreased volume. Choice B is incorrect as atherosclerosis affects arteries, not veins. Choice D is incorrect as incompetent jugular vein valves would lead to backflow, not distention.
Question 5 of 5
An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram?(Select the one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A. Hypertension alone may not directly warrant an electrocardiogram (ECG) as it primarily indicates high blood pressure. However, fatigue despite adequate rest, indigestion, and abdominal pain can be symptoms of underlying cardiac issues that require an ECG for further evaluation. Fatigue can be a sign of heart problems affecting oxygen delivery, while indigestion and abdominal pain can be symptoms of a heart attack or other cardiac conditions. Requesting an ECG based on these symptoms can help identify potential cardiac issues early on.