ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Put on sterile gloves and use a sterile catheter to suction. When coarse crackles are heard in a patient with a tracheostomy tube and they are unable to clear secretions, suctioning is necessary to maintain airway patency and prevent complications like respiratory distress. Using a sterile catheter ensures aseptic technique to prevent infection. Choices A and B are not appropriate as they do not address the immediate need for airway clearance. Choice D is incorrect because preoxygenation before suctioning is not indicated in this scenario and may delay necessary intervention.
Question 2 of 5
A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this client’s teaching? (Select all that do not apply.)
Correct Answer: D
Rationale: The correct answer is D because consuming high-fiber foods can actually slow down gastric emptying and exacerbate symptoms of bloating and gas in individuals with COPD. The other choices are relevant to nutrition in COPD management. A: Fluid restriction before meals helps prevent feeling too full and can aid in breathing efficiency. B: Resting before meals can reduce dyspnea during eating. C: Having smaller, more frequent meals can help maintain energy levels and prevent feeling too full, which can improve breathing.
Question 3 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 4 of 5
The nurse is performing a presurgical admission assessment of the client. Which client statement needs the most immediate follow-up?
Correct Answer: C
Rationale: The correct answer is C. The client statement "I took all my meds including warfarin and atenolol with a sip of water this morning" needs immediate follow-up because warfarin is a blood thinner and atenolol is a beta-blocker, both of which can have implications for surgery. Warfarin increases the risk of bleeding during surgery and atenolol can affect heart function. The nurse needs to assess the timing of medication intake and coordinate with the healthcare team to manage these medications appropriately before surgery to prevent complications. Choice A is not the most immediate concern since it is common practice to fast before surgery to reduce the risk of aspiration. Choice B, while important, does not require immediate follow-up as long as the donation meets the facility's guidelines. Choice D, bringing a health care directive, is important but not as urgent as addressing medication intake that can directly impact the surgery.
Question 5 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.