ATI RN
Introduction to Nursing Profession Quizlet Questions
Question 1 of 5
The nurse is revising a client's plan of care. During which step of the nursing process does such revision take place?
Correct Answer: D
Rationale: The correct answer is D: Evaluation. During the evaluation step of the nursing process, the nurse assesses the client's response to interventions, identifies if goals were met, and revises the care plan accordingly. This step ensures that the care provided is effective and individualized to the client's needs. A: Assessment is the step where data is collected about the client's condition, and it precedes the revision of the care plan. B: Planning involves setting goals and determining interventions, which is done before the revision of the care plan. C: Implementation is the step where the care plan is put into action, and it occurs before the evaluation and revision of the plan.
Question 2 of 5
When obtaining the temperature rectally, the nurse should insert the thermometer:
Correct Answer: B
Rationale: The correct answer is B (1 inch into the rectum). This is the proper depth for rectal temperature measurement as it ensures accurate readings without causing discomfort or injury. Inserting the thermometer too shallow (A) may lead to inaccurate readings, while inserting it too deep (C and D) can cause rectal perforation or injury. Optimal insertion depth balances accurate measurement and patient safety.
Question 3 of 5
A client who is NPO, comatose, and receiving oxygen has cracked lips, dry mucus membranes, swollen gums, and caked mucus on the tongue and teeth. The best intervention is to:
Correct Answer: A
Rationale: The correct answer is A: Swab the oral cavity with a normal saline solution as needed. This intervention is the best choice as it helps to keep the oral cavity moist, clean, and free from infection. Normal saline is gentle, non-irritating, and helps to maintain hydration. Cracked lips, dry mucus membranes, and caked mucus can lead to discomfort and potential infection in a comatose client. Summary: - Choice B (Swab the mouth every half-hour with lemon-glycerin swabs) is incorrect as lemon-glycerin swabs may irritate the oral mucosa and are not suitable for continuous use. - Choice C (Swab lips and mucus membranes with mineral oil) is incorrect as mineral oil can be harmful if aspirated and does not provide hydration. - Choice D (Swab the oral cavity with hydrogen peroxide followed with water) is incorrect as hydrogen peroxide can be harsh on delicate oral tissues and is not recommended for
Question 4 of 5
The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports that the child feels very warm" to touch. The first action by the nurse should be to:"
Correct Answer: C
Rationale: The correct answer is C, reassess the child's temperature. The nurse should first verify the mother's observation by assessing the child's temperature to confirm if there is an actual fever. This step ensures accurate information before any intervention. Reassuring the mother without verifying the temperature could lead to overlooking a potential issue. Offering cold oral fluids may provide temporary relief but doesn't address the underlying cause. Administering paracetamol should only be done based on a confirmed fever, not solely on the mother's perception of warmth. Therefore, reassessing the child's temperature is the most appropriate initial action.
Question 5 of 5
While doing nasopharyngeal suctioning on the client, the nurse can avoid trauma to the area by:
Correct Answer: C
Rationale: Rationale for correct answer (C): Applying no suction while inserting the catheter prevents trauma to the nasopharyngeal area by reducing the risk of damaging the delicate tissues. Inserting the catheter without applying suction allows for gentle and safe placement without causing injury. Summary of why other choices are incorrect: A: Applying suction for at least 60 seconds is not recommended as it can lead to excessive pressure and trauma to the area. B: While using clean gloves is important for infection control, it does not directly prevent trauma during suctioning. D: Rotating the catheter with gentle suction may still pose a risk of trauma as the twisting motion can cause damage to the tissues.