ATI RN
Introduction to Nursing Questions
Question 1 of 5
The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data should be of most concern to the nurse?
Correct Answer: B
Rationale: The correct answer is B: Blood pressure is 90/40 mm Hg. This is the most concerning assessment data because it indicates hypotension, which can be a sign of hypovolemic shock in a patient with massive burn injury. Hypotension can lead to inadequate tissue perfusion and organ failure. Choice A is not as concerning as low urine output can be expected in a hypovolemic patient. Choice C is not as critical as oral fluid intake may vary, but IV fluids can be administered if needed. Choice D, skin tenting, is a sign of dehydration but is not as immediately life-threatening as hypotension.
Question 2 of 5
Which information will be most important for the nurse to communicate to the health care provider about an older patient who has influenza?
Correct Answer: B
Rationale: The correct answer is B: Diffuse crackles in the lungs. This is the most important information to communicate because it indicates a potential complication like pneumonia in older patients with influenza. Crackles suggest fluid accumulation in the lungs, requiring prompt medical attention. Fever (A) and myalgia/headache (D) are common symptoms of influenza but may not indicate severe complications. Sore throat and cough (C) are typical symptoms and do not directly point to a serious issue like lung involvement.
Question 3 of 5
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
Correct Answer: B
Rationale: The correct answer is B: Ensure that informed consent is on the chart. This is the priority because obtaining informed consent is a legal and ethical requirement before any invasive procedure. It ensures the client understands the procedure, risks, benefits, and alternatives. Administering anxiolytic medication can help with anxiety but is not the priority. Reinforcing teaching and starting preoperative antibiotics are important but come after ensuring informed consent to prioritize the client's autonomy and safety.
Question 4 of 5
A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Assess the client's airway. This is the priority action because airway patency is always the top priority in any emergency situation. In this case, the packing for posterior nasal bleeding could potentially obstruct the client's airway, leading to respiratory distress or compromise. By assessing the client's airway first, the nurse can ensure that the client is able to breathe effectively. Choice A: Assessing the client's pain level is important but not the first priority in this situation. Choice B: Keeping the client's head elevated may be beneficial, but it is not the immediate priority over assessing the airway. Choice C: Teaching the client about the causes of nasal bleeding is important for education but not urgent in this situation.
Question 5 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: The correct answer is C: Increased right atrial pressure. Jugular venous distention (JVD) with the head of the bed elevated indicates increased pressure in the right atrium, leading to backflow and distention of the jugular veins. This is commonly seen in conditions like heart failure or fluid overload. Incorrect choices: A: Decreased fluid volume - This is incorrect because JVD is typically associated with volume overload, not decreased fluid volume. B: Jugular vein atherosclerosis - This is incorrect as atherosclerosis is a condition of the arteries, not the veins. D: Incompetent jugular vein valves - This is incorrect as incompetent valves may lead to venous reflux but are not directly related to JVD seen in this scenario.