ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
The physician has ordered an indwelling catheter inserted in a hospitalized male patient. The nurse is aware that:
Correct Answer: A
Rationale: The correct answer is A because the male urethra is indeed vulnerable to injury during catheter insertion due to its narrow and curved structure. Step 1: Understanding male anatomy - the male urethra is longer and more prone to injury compared to the female urethra. Step 2: Recognizing the importance of gentle and careful insertion to prevent damage. Step 3: Emphasizing the need for proper technique and training to minimize the risk of harm. Summary: Choice B is vague and not relevant to catheter insertion. Choice C is incorrect as a sterile technique is typically used for catheter insertion. Choice D is incorrect as the catheter should be inserted 6-7 inches into the male urethra, not 2-3 inches.
Question 2 of 5
For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select the one that does not apply.)
Correct Answer: D
Rationale: The correct answer is D: Red blood cells. Immunocompetence refers to the ability of the immune system to effectively respond to pathogens. Red blood cells are not directly involved in immune responses. Antibody-mediated immunity involves the production of antibodies by B cells to target pathogens. Cell-mediated immunity involves the activation of T cells to directly attack infected cells. Inflammation is a non-specific immune response that helps to eliminate pathogens. Red blood cells primarily function in oxygen transport and do not play a direct role in immune responses. Therefore, the correct answer is D as red blood cells do not need to be functional for a person to be immunocompetent.
Question 3 of 5
A postoperative patient has ineffective airway clearance. Which data would indicate to the nurse that interventions for this patient problem have been successful?
Correct Answer: C
Rationale: The correct answer is C because clear breath sounds indicate effective airway clearance. Clear breath sounds suggest that air is flowing freely through the airways, indicating successful interventions. A: Fluid intake does not directly reflect airway clearance. B: Using a spirometer may improve lung function but does not necessarily indicate effective airway clearance. D: Temperature is not directly related to airway clearance.
Question 4 of 5
A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance?
Correct Answer: B
Rationale: The correct answer is B: Daily weight. Daily weight monitoring is the most accurate way to evaluate fluid balance in a patient with hypovolemia as it directly reflects changes in body fluid status. Weight changes are a sensitive indicator of fluid retention or loss. Skin turgor (A) is more indicative of dehydration rather than overall fluid balance. Urine output (C) is important but may not capture total fluid status. Edema presence (D) indicates fluid overload rather than hypovolemia.
Question 5 of 5
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
Correct Answer: A
Rationale: The correct answer is A: Lung sounds. When a patient receives a hypertonic solution like 3% NaCl for hyponatremia, there is a risk of fluid shifting from the intravascular space to the interstitial spaces, potentially causing pulmonary edema and respiratory distress. Monitoring lung sounds is crucial to detect any signs of fluid overload and intervene promptly. B: Urinary output is important but not as critical as monitoring lung sounds in this context. C: Peripheral pulses and D: Peripheral edema are not directly related to the potential complications of receiving a hypertonic solution like 3% NaCl.