ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
The nurse teaches a patient who has asthma about peak flowmeter use. Which action by the patient indicates that teaching was successful?
Correct Answer: C
Rationale: The correct answer is C. When the patient uses albuterol for peak flows in the yellow zone, it indicates successful teaching because the yellow zone signifies caution, where the patient should take action to prevent worsening asthma symptoms. Using albuterol at this stage helps to manage symptoms before they escalate. Choice A is incorrect because inhaling rapidly through the peak flowmeter mouthpiece is not a correct technique and may lead to inaccurate results. Choice B is incorrect because montelukast is a controller medication and not used for immediate relief during asthma exacerbations. Choice D is incorrect because calling the healthcare provider when the peak flow is in the green zone is unnecessary as it indicates good lung function.
Question 2 of 5
The emergency department nurse is evaluating the outcomes for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?
Correct Answer: A
Rationale: The correct answer is A: 02 saturation is >90%. This is the best indicator because it directly measures the amount of oxygen in the blood, reflecting the effectiveness of the treatment in improving ventilation and oxygenation. - Choice B: No wheezes are audible. Wheezes can persist even after treatment, so absence of wheezes does not always indicate effectiveness. - Choice C: Respiratory rate is 16 breaths/min. While a normal respiratory rate is a good sign, it may not necessarily indicate the full effectiveness of the treatment. - Choice D: Accessory muscle use has decreased. Although a decrease in accessory muscle use is positive, it may not always correlate directly with improved oxygenation and ventilation.
Question 3 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 4 of 5
The client, returning from a coronary catheterization in which the femoral artery approach was used, sneezes. Which should be the nurse's priority intervention?
Correct Answer: D
Rationale: The correct answer is D: Check the insertion site. This is the priority intervention because sneezing can increase pressure in the femoral artery, potentially causing bleeding or dislodging the catheter. Checking the insertion site allows the nurse to assess for any signs of bleeding, hematoma, or catheter migration. Palpating pedal pulses (choice A) may be important but not as immediate as ensuring catheter site integrity. Measuring vital signs (choice B) is important but not the priority in this scenario. Assessing for urticaria (choice C) is not relevant to the immediate risk associated with sneezing post-catheterization.
Question 5 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.