ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
To determine how long the nasogastric tube must be to reach the stomach of the patient, the nurse should hold the end of the tube:
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. Holding the end of the nasogastric tube from the tip of the nose to the tip of the earlobe ensures proper placement. 2. This measurement aligns with the anatomical landmarks for the correct positioning of the tube into the stomach. 3. The tip of the earlobe to the xiphoid process correlates with the distance required for the tube to reach the stomach accurately. Summary of Incorrect Choices: A. Holding from the tip of the nose to the base of the neck is incorrect as it does not provide the accurate distance to reach the stomach. B. Holding from the tip of the nose to the middle of the cheek to the xiphoid process is incorrect as it includes an unnecessary measurement of the cheek. D. Holding eight to ten inches from the tip of the nose to the sternum is incorrect as it does not consider individual variations in anatomy.
Question 2 of 5
A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. The client remaining free of signs and symptoms of phlebitis indicates that the I.V. site is not infected or inflamed, ensuring proper infusion. 2. Phlebitis can lead to complications such as infection and thrombosis if not managed promptly. 3. Monitoring for phlebitis is crucial to prevent further complications and ensure the client's safety. 4. Options A, C, and D do not directly address the expected outcome of maintaining the client free of phlebitis symptoms.
Question 3 of 5
When percussing a client's chest, the nurse should identify which sound as a normal finding?
Correct Answer: C
Rationale: The correct answer is C: Resonance. When percussing the chest, resonance is the normal sound produced over healthy lung tissue. It indicates air-filled lungs. Hyperresonance (A) is an abnormal sound found in conditions like emphysema. Tympany (B) is a drum-like sound heard over air-filled areas like the stomach. Dullness (D) is heard over solid organs or areas with fluid accumulation, indicating abnormal findings. In summary, resonance is the expected sound over healthy lung tissue, making it the correct choice.
Question 4 of 5
In assessing oral temperature, how long should the nurse wait prior to reading the thermometer?
Correct Answer: C
Rationale: The correct answer is C (2-3 minutes). After placing the oral thermometer under the tongue, waiting for 2-3 minutes allows for an accurate reading of the oral temperature to be obtained. This timeframe ensures that the thermometer has enough time to accurately measure the body temperature. A (30 seconds) is too short for an accurate reading as it may not provide enough time for the thermometer to stabilize. B (1 full minute) is also not sufficient for an accurate reading. D (10 minutes) is too long and unnecessary, as it can lead to discomfort for the patient and does not improve the accuracy of the reading.
Question 5 of 5
What type of fever would the nurse document if the client had a wide range of temperature fluctuations over normal for a period of 24 hours?
Correct Answer: B
Rationale: The correct answer is B: Remittent fever. Remittent fever is characterized by wide temperature fluctuations over normal within a 24-hour period, without returning to normal in between. Intermittent fever has periods of normal temperature between spikes. Relapsing fever has recurring episodes of fevers with symptom-free intervals. Constant fever remains consistently elevated without fluctuations. Therefore, the correct choice is B as it aligns with the described temperature pattern.