ATI RN
Introduction to Nursing Chapter 1 Quizlet Questions
Question 1 of 5
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 6 breaths/min indicates severe respiratory distress, potentially leading to respiratory failure or arrest. This client needs immediate assessment and intervention to prevent further complications. A: A blood pressure of 100/50 mm Hg is low but not immediately life-threatening. B: A pulse of 118 beats/min is elevated but not as urgent as severe respiratory distress. D: A temperature of 96° F (35.6° C) is slightly below normal but not a priority compared to respiratory distress.
Question 2 of 5
When assessing a patient who is receiving a loop diuretic, the nurse looks for the manifestations of potassium deficiency, which would include what symptoms? (Select the one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Loop diuretics can lead to potassium deficiency, which can manifest as symptoms such as muscle weakness, constipation, and tinnitus. Dyspnea is not typically associated with potassium deficiency. Potassium plays a crucial role in muscle and nerve function, so muscle weakness is a common symptom. Constipation can occur due to altered smooth muscle function with low potassium levels. Tinnitus can be a result of inner ear disturbances related to potassium imbalances. However, dyspnea is more commonly associated with respiratory or cardiovascular issues rather than potassium deficiency.
Question 3 of 5
A patient at the clinic says, “I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though.” What focused assessment should the nurse make?
Correct Answer: D
Rationale: The correct answer is D because the patient's symptoms suggest a possible vascular issue, such as peripheral arterial disease (PAD). Palpating for the dorsalis pedis and posterior tibial pulses can help assess the adequacy of blood flow in the lower extremities. A decrease or absence of these pulses may indicate compromised blood flow, leading to symptoms like leg cramps and pain with activity. Choices A, B, and C are incorrect because they do not directly address the patient's symptoms of leg cramps and pain with walking, which are suggestive of a vascular etiology. Looking for tortuous veins, skin color changes in response to cold, or unilateral swelling, redness, and tenderness may be indicative of other conditions like varicose veins, Raynaud's phenomenon, or deep vein thrombosis, respectively. However, these symptoms are not consistent with the patient's presentation in this scenario.
Question 4 of 5
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
Correct Answer: D
Rationale: The correct interpretation of the arterial blood gas results provided is respiratory alkalosis (Choice D). 1. pH is high (alkalosis) at 7.48, indicating respiratory alkalosis. 2. PaO2 is within normal range, ruling out any significant oxygenation issues. 3. PaCO2 is low at 32 mm Hg, indicating respiratory alkalosis. 4. HCO3 is within normal range at 25 mEq/L, not indicative of metabolic acid-base imbalance. Summary: - Choice A (Metabolic acidosis) is incorrect as HCO3 is within normal range. - Choice B (Metabolic alkalosis) is incorrect as HCO3 is within normal range. - Choice C (Respiratory acidosis) is incorrect as PaCO2 is low, indicating alkalosis.
Question 5 of 5
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that do not apply.)
Correct Answer: D
Rationale: The correct answer is D because household light bulbs being fluorescent type is not directly related to safety when using oxygen at home. Oxygen supports combustion and can increase fire risk. A, B, and C are important safety factors as smoking can ignite oxygen, damaged electrical cords can cause sparks, and flammable liquids can also lead to fires.