ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
What is the most appropriate nursing diagnosis for a client expressing sadness about losing her breast?
Correct Answer: B
Rationale: The correct answer is B: Anticipatory Grieving. This nursing diagnosis is appropriate because the client is expressing sadness about a potential loss (her breast). Anticipatory Grieving involves experiencing the feelings and behaviors associated with the normal process of grieving before an actual loss occurs. In this case, the client is already grieving the potential loss of her breast, which aligns with the definition of anticipatory grieving. Incorrect options: A: Ineffective Individual Coping - This diagnosis is more about the client's ability to cope with stressors or life events, rather than specifically related to grief. C: Knowledge Deficit - This diagnosis is about a lack of understanding or information, which is not the primary issue in this scenario. D: Fear - While fear may be a component of the client's emotional response, it does not fully capture the anticipatory grieving process that the client is going through.
Question 2 of 5
What item is used to test cranial nerve II?
Correct Answer: D
Rationale: The correct answer is D: Snellen's chart. Cranial nerve II is the optic nerve responsible for vision. Snellen's chart is specifically designed to test visual acuity. It measures how well a person can see at various distances. Lateral gaze (A) is tested by cranial nerves III, IV, and VI. Coffee (B) and reflex hammer (C) are not used to test cranial nerve II.
Question 3 of 5
Raymond is a 5-year-old with chronic disease. He had just undergone insertion of central venous catheter via ultrasound. Which of the assessment data should you look first prior to administration of IV fluids?
Correct Answer: D
Rationale: The correct answer is D: Chest radiology results. This is the most critical assessment data to look at first before administering IV fluids to Raymond. By checking the chest radiology results, we can ensure that the central venous catheter is properly placed without any complications such as pneumothorax or malposition. This step is crucial for safe IV fluid administration. A: Serum osmolality and B: Serum electrolyte levels are important assessments but are not as immediate as checking the catheter placement. C: Intake and output record is important for monitoring fluid balance but does not take precedence over confirming the catheter placement.
Question 4 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 5 of 5
In intravenous therapy, the rule is to use veins of the upper extremities first. The superficial veins of the dorsal aspect of the hand are the preferred site. Which area of the wrist is highly sensitive and most painful site of venipuncture and must be avoided by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Inner aspect. This area of the wrist has a higher concentration of nerve endings, making it more sensitive and prone to causing more pain during venipuncture. It is essential for the nurse to avoid this area to prevent unnecessary discomfort and ensure successful venipuncture. The other choices (A: Outer aspect, B: Upper aspect, and C: Lower aspect) do not have the same high sensitivity and pain potential as the inner aspect, making them less critical to avoid during venipuncture.