ATI RN
Introduction to Nursing Quizlet Questions
Question 1 of 5
The nurse is administering a thrombolytic agent to a patient with an acute myocardial infarction. What patient data indicates that the nurse should stop the drug infusion?
Correct Answer: C
Rationale: The correct answer is C: Decreased level of consciousness. This indicates a potential complication such as intracranial bleeding, a serious adverse effect of thrombolytic therapy. Stopping the drug infusion is crucial to prevent further harm. Bleeding from the gums (A) is a common side effect of thrombolytic therapy but does not necessarily warrant stopping the infusion. An increase in blood pressure (B) may be expected due to the patient's condition and should be managed but does not indicate stopping the infusion. A nonsustained episode of ventricular tachycardia (D) may require treatment but does not mandate stopping the drug infusion unless it progresses to sustained ventricular tachycardia.
Question 2 of 5
The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to 88% while ambulating. What is the priority action of the nurse?
Correct Answer: B
Rationale: The correct answer is B: Administer PRN supplemental O2. A decrease in SpO2 from 93% to 88% indicates hypoxemia during ambulation, requiring immediate intervention to improve oxygenation. Administering supplemental O2 is crucial to prevent further complications. Notifying the healthcare provider (A) can cause delays in addressing the hypoxemia. Documenting the response to exercise (C) is important but not the immediate priority. Encouraging the patient to pace activity (D) is not sufficient to address the acute hypoxemia.
Question 3 of 5
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
Correct Answer: B
Rationale: The correct answer is B: Blood cultures from two sites. This should be implemented first to identify the specific bacteria causing the infection and guide appropriate antibiotic therapy. Cultures help determine the most effective treatment and prevent antibiotic resistance. Chest x-ray (A) can wait as it does not provide immediate treatment. Administering antibiotics like Cipro (C) should be based on culture results. Acetaminophen (D) can help with fever but is not the priority in this case.
Question 4 of 5
After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client’s understanding. Which action demonstrates that the client correctly understands the teaching?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Placing hands on the abdomen is key for feeling the rise and fall of the diaphragm during breathing. 2. This action indicates the client is focusing on belly breathing, which is characteristic of diaphragmatic breathing. 3. By placing hands on the abdomen, the client shows an understanding of the technique taught, ensuring proper execution. Summary: A: Lying on the side with knees bent does not directly relate to diaphragmatic breathing. C: Lying in a prone position with straight doesn't specify the focus on abdominal breathing. D: Placing hands above the head is unrelated to diaphragmatic breathing technique.
Question 5 of 5
A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused around reduction of which specific problem associated with this type of heart failure?
Correct Answer: C
Rationale: The correct answer is C: Bilateral lung crackles. Left-sided heart failure causes fluid buildup in the lungs, leading to crackles on auscultation. Interventions should focus on reducing pulmonary congestion to improve breathing. Ascites (A) is associated with right-sided heart failure. Pedal edema (B) is a symptom of right-sided heart failure due to fluid retention in the lower extremities. Jugular vein distention (D) is a sign of right-sided heart failure. Focusing on reducing bilateral lung crackles is crucial in managing left-sided heart failure.