ATI RN
Introduction to Professional Nursing Questions
Question 1 of 5
What assessment finding would concern the nurse most in a client with crepitus and decreased breath sounds after a motor vehicle accident?
Correct Answer: C
Rationale: The correct answer is C: Trachea deviating to the right. This finding indicates a tension pneumothorax, a life-threatening condition that requires immediate intervention. Crepitus and decreased breath sounds suggest air in the pleural space, causing the lung to collapse. Tracheal deviation to the unaffected side is a critical sign of tension pneumothorax, indicating a shift of mediastinal structures. Choices A, B, and D do not address the immediate concern of tracheal deviation and the potential for a tension pneumothorax in this scenario.
Question 2 of 5
Where should the aortic valve be assessed?
Correct Answer: B
Rationale: The correct answer is B: 2nd ICS to the right. The aortic valve is best assessed at the 2nd intercostal space (ICS) to the right of the sternum. This is where the aortic valve can be auscultated most accurately due to its anatomical positioning. Assessing at the 3rd ICS to the left (choice A) would be incorrect as it is more indicative of the pulmonic valve. Choices C and D are also incorrect as they do not align with the accurate anatomical location of the aortic valve.
Question 3 of 5
What should the nurse do if a client with urinary incontinence has a urine output of 60ml over 3 hours?
Correct Answer: D
Rationale: The correct answer is D because palpating the patient's hypogastrium can help assess for bladder distension, which could be causing the urinary incontinence. By palpating the hypogastrium, the nurse can determine if the bladder is full and if the patient needs to void. This action is more appropriate than the other choices because stimulating the patient to urinate (choice A) may not address the underlying cause, informing the head nurse (choice B) is not an immediate action for this situation, and positioning the patient on his left side (choice C) is not directly related to assessing bladder distention.
Question 4 of 5
You are currently inserting an IV line into a client. While you were inserting it, which of the following signs should you stop advancing the catheter?
Correct Answer: D
Rationale: Correct answer: D. The blood return shows in the backflash chamber of the catheter. Rationale: When inserting an IV line, the appearance of blood return in the backflash chamber indicates proper placement within the vein. This signifies that the catheter tip is in the vein, and further advancement should be stopped to prevent complications like infiltration. Options A, B, and C do not provide direct indications of proper catheter placement and do not offer concrete guidance on when to stop advancing the catheter.
Question 5 of 5
When assessing Frank for chest percussion or chest vibration and postural drainage, Mario would focus on the following, EXCEPT:
Correct Answer: C
Rationale: The correct answer is C because when assessing for chest percussion or chest vibration and postural drainage, Mario should focus on the client's respiratory status, not breath sounds and location of congestion. Breath sounds and congestion assessment are important for lung auscultation, not for the actual treatment techniques. A: Monitoring food and fluid intake is important to prevent aspiration during treatment. B: Respiratory rate indicates the client's respiratory effort and response to treatment. D: Teaching relatives to perform the procedure ensures continuity of care and client support. Therefore, C is the correct answer as it is not directly related to the assessment for these specific treatments.