ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
What action should a nurse take if a pleur-evac attached to a chest tube breaks?
Correct Answer: C
Rationale: The correct answer is C: Place the end of the tube in sterile water. This action prevents air from entering the pleural space and causing a pneumothorax. Clamping the chest tube (Option A) can lead to tension pneumothorax. Notifying the physician (Option B) is important but should be done after securing the chest tube. Repositioning the client in the Fowler's position (Option D) is not relevant in this scenario. By placing the tube in sterile water, the nurse can maintain the integrity of the closed drainage system and prevent complications.
Question 2 of 5
Mr. Tony is nervous about a colonoscopy scheduled for tomorrow. The nurse describes the test explaining that:
Correct Answer: B
Rationale: The correct answer is B because a colonoscopy is a procedure that allows visual examination of the large intestine. During a colonoscopy, a flexible tube with a camera is inserted through the rectum to examine the colon for abnormalities like polyps or cancer. The other choices are incorrect because: A: Visual examination of the esophagus and stomach is typically done using an upper endoscopy. C: A radiographic examination uses X-rays, not a camera, to visualize structures. D: A fluoroscopic examination involves real-time X-ray images and is often used for examining the small intestine, not the large intestine like in a colonoscopy.
Question 3 of 5
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?
Correct Answer: C
Rationale: The correct answer is C: Rising body temperature. When a patient with a systemic bacterial infection experiences a shaking chill, it indicates that the body is trying to generate heat to combat the infection. The next assessment finding the nurse would expect is a rising body temperature as the body's immune response kicks in to fight off the infection. Skin flushing (choice A) is less likely as the patient is feeling cold initially. Muscle cramps (choice B) are not typically associated with this scenario. Decreasing blood pressure (choice D) may be a later complication but is not the immediate next assessment finding after a shaking chill.
Question 4 of 5
A new nurse reads a client has a wound “healing by second intention” and asks what that means. Which description by the charge nurse is most accurate?
Correct Answer: C
Rationale: The correct answer is C because healing by second intention refers to a wound that is left open to fill in with granulation tissue. This process allows for the wound to heal from the inside out, promoting tissue regeneration. Explanation: 1. Option A is incorrect because healing by second intention does not involve approximating or stitching wound edges together. 2. Option B is incorrect because stapling a wound after an infection does not necessarily relate to healing by second intention. 3. Option D is incorrect because although the wound may be contaminated, healing by second intention does not mean it cannot be closed at all. In summary, the correct answer is C because it accurately describes the process of healing by second intention, which involves allowing an open wound to fill in with granulation tissue.
Question 5 of 5
A nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the nurse learn? (Select the one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A because basophils are not only involved in the general inflammatory process but are primarily associated with allergic reactions. Basophils release histamine and other chemicals that contribute to allergic responses. Choice B is incorrect because eosinophils do increase during allergic reactions and parasitic invasion. Choice C is correct as macrophages are known to participate in multiple episodes of phagocytosis, clearing pathogens and debris. Choice D is also correct as monocytes do differentiate into macrophages once they enter body tissues to perform their immune functions.