ATI RN
Introduction to Nursing Quizlet Questions
Question 1 of 5
To administer a soap-suds enema to an adult before abdominal surgery, the nurse should:
Correct Answer: C
Rationale: The correct answer is C because raising the fluid container 12-18 inches above the patient's anus ensures a slow, controlled flow of the enema solution into the rectum, allowing for proper cleansing without causing discomfort or injury. This height creates enough pressure to facilitate the flow but prevents excessive pressure that could lead to bowel perforation. Choice A is incorrect because cold water can cause discomfort and cramping, while warm water is recommended for its soothing effect. Choice B is incorrect as the rectal tube should be inserted 3-4 inches into the rectum to ensure proper administration. Choice D is incorrect as removing and reinserting the rectal tube multiple times can disrupt the flow and increase the risk of introducing air into the rectum.
Question 2 of 5
A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?
Correct Answer: B
Rationale: The correct answer is B: Increase your fluid intake to 2 to 3 L per day. This instruction is important after extracorporeal shock wave lithotripsy to help flush out the stone fragments and prevent urinary tract infections. Increasing fluid intake also helps prevent dehydration and promotes kidney function. A: Taking temperature every 4 hours is not necessary post-lithotripsy unless the client develops signs of infection. C: Applying an antibacterial dressing daily is not typically required after lithotripsy unless specifically instructed by the healthcare provider. D: Urine turning cherry red after lithotripsy is due to blood in the urine, which is expected, but this should resolve within 24-48 hours, not 5 to 7 days.
Question 3 of 5
The client is scheduled for an intravenous pyelograph (IVP) to determine the location of the renal calculi. Which of the following measures would be most important for the nurse to include in pretest preparation?
Correct Answer: C
Rationale: The correct answer is C: Checking the client's history for allergy to iodine. This is crucial for IVP as iodine contrast dye is used, and an allergic reaction can occur. It is important to identify any potential allergies beforehand to prevent a serious reaction during the test. A: Ensuring adequate fluid intake on the day of the test - While hydration is important, it is not the most critical factor in pretest preparation for IVP. B: Preparing the client for the possibility of bladder spasms during the test - While informing the client about possible discomfort is important, it is not as essential as identifying allergies to iodine. D: Determining when the client last had a bowel movement - Bowel movement history is not directly related to the IVP procedure and is not as critical as checking for iodine allergy.
Question 4 of 5
A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first?
Correct Answer: D
Rationale: The correct answer is D because assessing the right leg for pulses, skin color, and temperature is the priority to determine the perfusion status and tissue viability. This step is crucial in identifying any vascular compromise that could be contributing to the nonhealing pressure injury. Drawing blood for albumin, prealbumin, and total protein (A) can provide information on the client's nutritional status but is not the immediate priority. Preparing for a wound culture (B) is important for determining the presence of infection but should come after assessing perfusion. Instructing the client to elevate the foot (C) can help with reducing edema but is not the first action when dealing with a nonhealing pressure injury.
Question 5 of 5
A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?
Correct Answer: D
Rationale: The correct answer is D because the use of multiple herbs and supplements can interact with anesthesia and other medications during surgery, potentially causing adverse effects. It is crucial for the surgical team to be aware of this information to ensure the client's safety. A: Allergy to bee and wasp stings - Although allergies are important, this information may not directly impact the surgical procedure and can be managed with standard protocols. B: History of lactose intolerance - Lactose intolerance typically does not have a significant impact on surgery unless specific dietary restrictions are necessary, which can be easily managed. C: No previous experience with surgery - While this information is relevant for emotional support, it does not directly affect the surgical procedure itself.