ATI RN
Introduction to Nursing Pdf Questions
Question 1 of 5
What finding should the nurse expect during the assessment of a young adult with infective endocarditis (IE)?
Correct Answer: B
Rationale: The correct answer is B: A new regurgitant murmur. In infective endocarditis, vegetation on heart valves can cause valve dysfunction, leading to new regurgitant murmurs. This is a classic finding in IE assessment. Substernal chest pressure (A) is more common in conditions like angina or myocardial infarction. Pruritic rash on the chest (C) is not typically associated with IE. Involuntary muscle movement (D) is not a common finding in IE and is more suggestive of neurological conditions.
Question 2 of 5
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take?
Correct Answer: D
Rationale: The correct answer is D because administering pain medication will help alleviate the client's discomfort, enabling them to take deep breaths essential for lung expansion following chest tube placement. Deep breathing prevents complications like atelectasis. Option A is incorrect as ambulation may be painful. Option B does not address the client's pain issue. Option C is wrong because shallow breaths can lead to lung complications.
Question 3 of 5
Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway?
Correct Answer: A
Rationale: The correct answer is A: Weak cough effort. A weak cough effort indicates ineffective airway clearance as coughing helps clear secretions and foreign particles from the airway. Profuse green sputum (B) indicates infection but not necessarily inability to clear the airway. Respiratory rate of 28 breaths/min (C) and low SpO2 (D) suggest respiratory distress but do not specifically indicate inability to clear the airway. Weak cough effort directly relates to the airway's ability to clear, making it the most specific finding.
Question 4 of 5
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that do not apply.)
Correct Answer: D
Rationale: The correct answer is D because fluorescent light bulbs can pose a fire hazard when used near oxygen due to their high energy output. Oxygen supports combustion, and fluorescent bulbs can generate heat and sparks. A, B, and C are incorrect because they are factors that the nurse should assess for safe oxygen use in the home. Smoking prohibition prevents fire risks, functional electrical cords prevent electrical hazards, and storing flammable liquids away from oxygen reduces the risk of explosions.
Question 5 of 5
After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Ask the patient whether medications have been taken as directed. This is the next appropriate action because the patient is still testing positive for AFB despite being on the appropriate TB treatment regimen for 2 months. By assessing medication adherence, the nurse can determine if the lack of improvement is due to non-compliance. If the patient has been taking the medications as prescribed, then further evaluation for drug-resistant TB or other factors may be necessary. Choice A is incorrect because assuming drug resistance without confirming adherence could lead to unnecessary treatment changes. Choice B is not the immediate priority as ensuring medication adherence should come first. Choice D is premature without first confirming adherence and evaluating other possible reasons for treatment failure.