ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
The nurse further asked the client to move her tongue side to side & up and down. The nurse is checking what cranial nerve with this process?
Correct Answer: B
Rationale: The correct answer is B: Glossopharyngeal nerve. Moving the tongue side to side & up and down tests the function of the glossopharyngeal nerve (cranial nerve IX), responsible for controlling the muscles of the tongue and throat. The other choices are incorrect because: A: Facial nerve (VII) controls facial expressions, not tongue movements. C: Trigeminal nerve (V) controls chewing and sensation in the face, not tongue movement. D: Abducens nerve (VI) controls eye movement, not tongue movements.
Question 2 of 5
A nurse must verify the client's identity before administering medication. The safest way to verify identity is to:
Correct Answer: B
Rationale: The correct answer is B: Check the client's identification band. This method is the safest way to verify the client's identity because it directly links the client to a unique identification band that is specifically assigned to them. This ensures accuracy and minimizes the risk of error. A: Asking the client his name may not be reliable as the client could provide incorrect information. C: Stating the client's name aloud and having them repeat it relies on the client's memory and verbal confirmation, which may not be foolproof. D: Checking the room number and the client's name on the bed is not as direct and specific as checking the client's identification band, which could lead to confusion if there are multiple clients in the same room.
Question 3 of 5
The medication order is chlorate hydrate 400mg. The bottle reads chlorate hydrate 0.1 g / capsules. How many capsules should be given?
Correct Answer: D
Rationale: To find the number of capsules needed, convert 400mg to grams (400mg = 0.4g). Then divide the total amount required (0.4g) by the strength of each capsule (0.1g/capsule). This results in 4 capsules needed (0.4g / 0.1g/capsule = 4 capsules). Choice D is correct as it aligns with the calculation. Choices A, B, and C are incorrect as they do not match the calculated amount required based on the medication strength and dosage.
Question 4 of 5
What action should a nurse take if a pleur-evac attached to a chest tube breaks?
Correct Answer: C
Rationale: The correct answer is C: Place the end of the tube in sterile water. This action prevents air from entering the pleural space and causing a pneumothorax. Clamping the chest tube (Option A) can lead to tension pneumothorax. Notifying the physician (Option B) is important but should be done after securing the chest tube. Repositioning the client in the Fowler's position (Option D) is not relevant in this scenario. By placing the tube in sterile water, the nurse can maintain the integrity of the closed drainage system and prevent complications.
Question 5 of 5
When using a cane for maximal support, the nurse is aware that the client should:
Correct Answer: A
Rationale: The correct answer is A: Hold the cane on the weaker side. This is correct because it provides maximal support and stability for the client. By holding the cane on the weaker side, the client can shift weight off the weaker leg, reducing strain and improving balance. Choice B is incorrect because weight should be shifted to the stronger side, not evenly distributed. Choice C is incorrect as keeping the elbow stiff can lead to discomfort and limited mobility. Choice D is incorrect as the stronger foot should advance ahead of the cane for stability.