ATI RN
Introduction to Nursing 203 Quizlet Questions
Question 1 of 5
The nurse is performing an assessment on a patient brought to the emergency department for treatment for dehydration. The nurse assesses a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5 C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse notes cool, clammy skin. Which diagnosis does the nurse suspect?
Correct Answer: A
Rationale: The correct diagnosis is A: Fluid volume deficit (FVD). The patient's vital signs and symptoms indicate hypovolemia. A respiratory rate of 26 breaths/minute, heart rate of 110 beats/minute, low blood pressure, high temperature, dizziness upon position change, and cool, clammy skin are all indicative of FVD. The increased respiratory and heart rates are compensatory mechanisms to maintain oxygen delivery in response to decreased circulating volume. The low blood pressure and cool, clammy skin suggest poor perfusion due to decreased fluid volume. These findings align with the clinical presentation of dehydration. Summary of other choices: B: Fluid volume excess (FVE) - Contradicted by the patient's low blood pressure, cool, clammy skin, and symptoms of dehydration. C: Mild extracellular fluid (ECF) deficit - Symptoms and vital signs are indicative of severe rather than mild fluid deficit. D: Renal failure - Not supported by the information provided;
Question 2 of 5
The client is to receive a scheduled dose of digoxin has a irregular apical pulse of 92 bpm and a serum potassium of 3.9 meq/l which nursing documentation reflects the most appropriate action?
Correct Answer: A
Rationale: Rationale: 1. Digoxin is indicated for rapid apical pulse. 2. Digoxin has narrow therapeutic range. 3. Potassium level is within normal limits (WNL). 4. Notifying physician or holding digoxin may delay treatment. 5. Monitoring for toxicity is not proactive. 6. Rechecking pulse in 1 hour is unnecessary and may lead to delay in treatment. Summary: Choice A is correct because the potassium level is normal and digoxin is appropriate for rapid pulse. Choices B, C, and D are incorrect as they may delay necessary treatment or not address the current situation effectively.
Question 3 of 5
A patient who has just undergone a colon resection complains to a nurse that he felt something pop under his dressing while trying to get out of bed.the nurse removes the dressing and finds that dehiscence of the wound has occurred.what nursing action should be implemented first?
Correct Answer: A
Rationale: The correct answer is A: Cover the wound with sterile dressings saturated with normal saline. This action helps to maintain a moist environment for wound healing and prevent further contamination. The step-by-step rationale is: 1) Covering the wound with sterile dressings helps protect the wound from infection and further trauma. 2) Saturating the dressings with normal saline helps keep the wound moist, promoting healing. 3) This immediate action is crucial in preventing complications such as infection and further wound dehiscence. Summary of other choices: B: Notifying the surgeon immediately is important, but covering the wound to protect it should be done first. C: Applying pressure to the wound can further damage the tissue and should not be done. D: Placing the patient in Trendelenburg position is not necessary for wound dehiscence and does not address the immediate need to protect the wound.
Question 4 of 5
A nurse in a walk-in healthcare setting provides technical services, such as, administering medications, determines the priority of care needs, and provides patient teaching on all aspects of care. Which of the following terms best describes this type of healthcare setting?
Correct Answer: C
Rationale: The correct answer is C: ambulatory center. This setting is best described as an ambulatory center because it provides same-day medical services without the need for an overnight stay. Ambulatory centers offer a wide range of medical services, including administering medications, determining care priorities, and patient education. Hospitals (choice A) typically provide more acute care services requiring overnight stays. Physicians' offices (choice B) usually offer routine check-ups and consultations but may not provide the same level of technical services as an ambulatory center. Long-term care facilities (choice D) focus on providing extended care for individuals who require ongoing assistance with daily activities, which is not the primary function of the described healthcare setting.
Question 5 of 5
A nurse is admitting a patient to the hospital for surgery. Which of the following pieces of information must be obtained from the patient? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: date of birth. It is essential to obtain the patient's date of birth for accurate identification and to ensure the correct patient receives the appropriate care. This information is crucial for confirming the patient's identity and preventing medical errors. Explanation for Incorrect Choices: A: Address - While obtaining the patient's address is important for communication and follow-up purposes, it is not a critical piece of information that must be obtained during the admission process. C: Admitting physician - Knowing the admitting physician is important for coordination of care, but it is not crucial information that must be obtained directly from the patient. D: Symptoms experienced - While knowing the symptoms experienced by the patient is important for medical history and assessment, it is not a piece of information that must be obtained directly from the patient during the admission process.