ATI RN
Introduction to Nursing 203 Quizlet Questions
Question 1 of 5
The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:
Correct Answer: C
Rationale: The correct answer is C because it is a specific, measurable, achievable, relevant, and time-bound (SMART) goal. Walking from his room to the end of the hall and back before discharge is specific in distance, measurable in terms of achievement, achievable based on the client's condition, relevant to his recovery, and time-bound before discharge. Choice A is not measurable in terms of progress. Choice B is vague and not specific. Choice D is not directly related to the client's recovery from mitral valve replacement. Therefore, choice C is the best example of a measurable client outcome goal.
Question 2 of 5
The nurse documents the client’s pulse as weak and thready. This pulse characteristic refers to:
Correct Answer: C
Rationale: Step-by-step rationale: 1. Weak and thready pulse refers to the volume of the pulse. 2. Pulse volume indicates the strength or force of the heartbeat. 3. A weak and thready pulse suggests a low volume of blood being ejected with each heartbeat. 4. This characteristic is important in assessing the client's perfusion status. Summary: A. Pulse rhythm: Refers to the regularity of the pulse pattern, not the strength. B. Pulse deficit: Refers to a difference between the apical and radial pulse rates, not the strength. C. Pulse volume: Correct answer. Reflects the strength or force of the heartbeat. D. Pulse rate: Refers to the number of heartbeats per minute, not the strength.
Question 3 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 4 of 5
The client has developed liver failure. Which of the following laboratory values would Nurse Irene expect to have alterations?
Correct Answer: B
Rationale: The correct answer is B: Clotting factors. Liver failure can lead to impaired synthesis of clotting factors, resulting in abnormal coagulation tests. A: Blood urea nitrogen and creatinine are more related to kidney function. C: Creatinine kinase is an enzyme related to muscle breakdown. D: C-reactive protein is a marker of inflammation and infection, not specific to liver function. In liver failure, alterations in clotting factors are commonly seen due to the liver's role in synthesizing these proteins.
Question 5 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.