ATI RN
Introduction to Nursing 203 Quizlet Questions
Question 1 of 5
The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
Correct Answer: C
Rationale: The correct answer is C: Reposition every 2 hours. Repositioning every 2 hours helps to relieve pressure on bony prominences, reducing the risk of skin breakdown. This measure promotes circulation and tissue oxygenation. A: Placing the client in a wheelchair for extended periods can increase pressure on bony areas, leading to skin breakdown. B: Padding bony prominences may provide some protection but does not address the root cause of pressure. D: Massaging reddened areas can cause further damage to fragile skin and should be avoided.
Question 2 of 5
You are to insert an indwelling catheter for a female client, after the insertion of the catheter still the urine does not flow. You made a conclusion that you might have inserted the catheter into the vagina. In response to this, you should:
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Leave the catheter in place and insert another one): If urine does not flow after catheter insertion, it indicates the catheter may be in the vagina. Leaving the catheter in place prevents further complications. Inserting another catheter correctly ensures urine drainage. Removing the catheter and reinserting it (choice A) risks causing trauma. Irrigating the catheter with saline (choice B) is unnecessary and may worsen the situation. Inserting the catheter further (choice D) can cause harm.
Question 3 of 5
The minimum time in washing each hand should never be below:
Correct Answer: C
Rationale: The correct answer is C (15 seconds) as recommended by health authorities. Washing hands thoroughly for at least 15 seconds ensures proper removal of dirt, germs, and viruses. This duration allows for adequate friction and coverage of all areas of the hands, including between fingers and under nails. Option A (5 seconds) is too short and insufficient for effective cleaning. Option B (10 seconds) may not provide thorough cleaning, especially in challenging situations. Option D (30 seconds) is longer than necessary and may not offer additional benefits compared to 15 seconds. Therefore, option C is the most appropriate choice for proper hand hygiene.
Question 4 of 5
The physician orders a blood transfusion for a client. The nurse should anticipate using an I.V. access device of which size?
Correct Answer: C
Rationale: The correct answer is C (18G) because a blood transfusion requires a larger gauge size to allow for the rapid flow of blood products without causing hemolysis. 18G provides a larger diameter for quick transfusion. Option A (23G) and D (25G) are too small for efficient blood flow. Option B (21G) is slightly larger but may still impede the flow rate compared to 18G, making it less optimal for blood transfusion.
Question 5 of 5
Which nursing action would compromise safety when administering a tube feeding to a client with a tracheostomy?
Correct Answer: A
Rationale: Correct Answer: A - Place the client in supine position Rationale: 1. When administering tube feeding to a client with a tracheostomy, the head of the bed should be elevated at least 30 degrees to prevent aspiration. 2. Placing the client in a supine position increases the risk of aspiration and compromises safety. 3. The supine position can lead to reflux of feeding contents into the trachea, causing respiratory complications. Summary of Incorrect Choices: B: Aspirating residual stomach contents is a standard practice to prevent overfeeding, not directly related to compromising safety. C: Determining tube placement is essential for safety, so this action does not compromise safety. D: Checking bowel sounds is unrelated to the administration of tube feeding to a client with a tracheostomy and does not compromise safety.