ATI RN
Introduction to Nursing 203 Quizlet Questions
Question 1 of 5
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that do not apply.)
Correct Answer: A
Rationale: Rationale: A chest x-ray is not necessary for monitoring complications in type 2 diabetes. The correct tests are B, C, and D. Blood pressure monitoring is crucial for assessing cardiovascular risk, serum creatinine for kidney function, and urine microalbuminuria for early detection of diabetic nephropathy. A chest x-ray does not directly relate to diabetes complications and is not a routine annual test for diabetic patients.
Question 2 of 5
The nurse teaching a group of adults about cancer warning signs presents to the group a list of the seven possible warning signs of cancer that is used by the American Cancer Society. What should this list NOT include?
Correct Answer: A
Rationale: The correct answer is A: Areas of alopecia. This is because alopecia, which refers to hair loss, is not typically recognized as a common warning sign of cancer according to the American Cancer Society. The other choices (B, C, D) are commonly known warning signs of cancer such as sores that do not heal, nagging cough or hoarseness, and indigestion or difficulty swallowing, respectively. It is important for the nurse to provide accurate and relevant information to the group in order to educate them effectively on cancer warning signs.
Question 3 of 5
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-Ib weight gain in the past 3 days. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Assess the patient for manifestations of acute heart failure. In this scenario, the patient's sudden weight gain could indicate fluid retention, a common sign of acute heart failure exacerbation. Assessing the patient for other symptoms such as shortness of breath, increased fatigue, or edema can help determine if the patient's condition is worsening. This immediate assessment is crucial for prompt intervention to prevent further complications. Choices A, C, and D are incorrect as they do not address the urgency of the situation. Teaching about sodium restriction is important but not the priority in this acute situation. Asking about medication use and dietary intake can wait until the immediate concern of acute heart failure exacerbation is addressed.
Question 4 of 5
The nurse is performing an assessment on a patient brought to the emergency department for treatment for dehydration. The nurse assesses a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5 C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse notes cool, clammy skin. Which diagnosis does the nurse suspect?
Correct Answer: A
Rationale: The correct diagnosis is A: Fluid volume deficit (FVD). The patient's vital signs and symptoms indicate hypovolemia. A respiratory rate of 26 breaths/minute, heart rate of 110 beats/minute, low blood pressure, high temperature, dizziness upon position change, and cool, clammy skin are all indicative of FVD. The increased respiratory and heart rates are compensatory mechanisms to maintain oxygen delivery in response to decreased circulating volume. The low blood pressure and cool, clammy skin suggest poor perfusion due to decreased fluid volume. These findings align with the clinical presentation of dehydration. Summary of other choices: B: Fluid volume excess (FVE) - Contradicted by the patient's low blood pressure, cool, clammy skin, and symptoms of dehydration. C: Mild extracellular fluid (ECF) deficit - Symptoms and vital signs are indicative of severe rather than mild fluid deficit. D: Renal failure - Not supported by the information provided;
Question 5 of 5
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient’s ventilation?
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to sit in a chair and lean forward. This position helps improve ventilation by expanding the chest cavity, allowing for better lung expansion and increased air exchange. Leaning forward also reduces pressure on the diaphragm, making it easier for the patient to breathe. Choice B (head elevated 15 degrees) does not provide as much chest expansion as leaning forward. Choice C (Trendelenburg position) places the patient with their head lower than the feet, which can worsen breathing difficulties. Choice D (high-Fowler’s position with knees flexed) does not promote optimal lung expansion compared to leaning forward. In summary, choice A is the best option as it maximizes chest expansion and supports ventilation in a patient with poor gas exchange due to COPD.