ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 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 2 of 5
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?
Correct Answer: B
Rationale: Step 1: Documenting the assessment is appropriate as redness and warmth around the incision on the first postoperative day are common signs of normal inflammation. Step 2: This action allows for tracking changes in the wound over time. Step 3: It provides a baseline for comparison in case the condition worsens. Step 4: Obtaining wound cultures (A) is premature as it is not indicated for initial signs of inflammation. Step 5: Notifying the health care provider (C) may be necessary if the condition worsens, but it is not the first step. Step 6: Assessing the wound every 2 hours (D) is excessive and unnecessary unless there are other concerning symptoms.
Question 3 of 5
A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find?
Correct Answer: D
Rationale: The correct answer is D because beta blockers lower heart rate by blocking the effects of adrenaline on the heart. This results in a decreased pulse rate. Choice A is incorrect because beta blockers typically lower blood pressure. Choice B is incorrect as beta blockers do not directly affect respiratory rate. Choice C is incorrect because beta blockers do not affect oxygen saturation directly. Overall, the expected assessment after administering a beta blocker would be a decrease in heart rate (pulse).
Question 4 of 5
The client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which of the following documented in the client's record is an expected finding with this client?
Correct Answer: B
Rationale: The correct answer is B: Hyperinflation of lungs documented by chest x-ray. In COPD exacerbation, the airways become inflamed and narrowed, leading to air trapping and hyperinflation of the lungs. This is evidenced on chest x-ray by increased lung volume and flattened diaphragms due to overinflation. Choices A, C, and D are incorrect because in COPD exacerbation, oxygen saturation typically decreases with ambulation due to impaired gas exchange, a widened diaphragm is not a typical finding on chest x-ray in COPD exacerbation, and a shortened expiratory phase is more commonly seen in obstructive lung diseases like asthma rather than COPD exacerbation.
Question 5 of 5
Following an acute myocardial infarction a previously healthy 63 yr old develops clinical manifestations of heart failure the nurse anticipates discharge teaching will include information about?
Correct Answer: A
Rationale: The correct answer is A: Angiotension converting enzyme (ACE) inhibitors. Post-myocardial infarction, ACE inhibitors are crucial in managing heart failure by reducing afterload, improving cardiac function, and preventing adverse remodeling. ACE inhibitors also decrease mortality rates in patients with heart failure. Beta blockers (B) are also important but are typically initiated later in the treatment plan. Calcium channel blockers (C) are not first-line agents in heart failure treatment. Diuretics (D) are used to manage fluid overload but are not specifically indicated for post-myocardial infarction heart failure management.