ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
What is the most important nursing action if a client complains of severe pain after a renal biopsy?
Correct Answer: B
Rationale: The correct answer is B: Call the doctor immediately. This is the most important nursing action because severe pain after a renal biopsy could indicate a serious complication such as internal bleeding or organ damage, which requires prompt medical intervention. Calling the doctor ensures timely assessment and appropriate treatment. Rationale for other choices: A: Assess for malingering - In this context, assuming the client is faking or exaggerating pain can delay necessary medical attention. C: Assess pain scale - While important, assessing pain scale alone does not address the urgency of the situation. D: Give analgesic as ordered - Administering pain medication without consulting the doctor first could mask symptoms of a serious complication and delay proper treatment.
Question 2 of 5
Nurse Jasmine provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?
Correct Answer: B
Rationale: The correct answer is B: "I need to restrict my activity while this catheter is in place." This statement is incorrect because clients with a PICC line do not need to restrict their activity. They can resume normal activities as tolerated unless otherwise instructed by their healthcare provider. Restricting activity unnecessarily can lead to deconditioning and reduced quality of life. A: "I need to wear a MedicAlert tag or bracelet." - This is a correct statement as it helps alert healthcare providers about the presence of the PICC line in case of an emergency. C: "I need to keep the insertion site protected when in the shower or bath." - This is a correct statement to prevent infection and maintain the integrity of the PICC line. D: "I need to check the markings on the catheter each time the dressing is changed." - This is a correct statement as it helps ensure the catheter is in the correct position.
Question 3 of 5
Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:
Correct Answer: B
Rationale: The correct answer is B: Theresa with anemia. Anemia is a condition characterized by a decrease in red blood cells or hemoglobin levels, leading to reduced oxygen-carrying capacity. This impairs the transport of oxygen from the lungs to the tissues, affecting overall oxygen delivery and tissue oxygenation. A: Carol with a tumor in the brain - Brain tumor does not directly impact oxygen transport from the lungs to tissues. C: Sonny Boy with a fracture in the femur - Fracture does not affect oxygen transport. D: Brigette with diarrhea - Diarrhea may lead to dehydration and electrolyte imbalances but does not directly affect oxygen transport.
Question 4 of 5
A client with a chest tube attached to a Pleurevac drainage system wants to get out of bed. While the nurse is assisting the client, the chest tubing accidentally gets caught in the bed rail and disconnects and the Pleur-Evac drainage system falls over and cracks. The nurse takes which immediate action?
Correct Answer: C
Rationale: The correct immediate action is to immerse the chest tube in a bottle of sterile normal saline. This is because it helps to maintain the sterility of the system and prevents air from entering the pleural space, thus avoiding a potential pneumothorax. Clamping the chest tube (choice A) can lead to tension pneumothorax. Applying petroleum gauze over the end of the chest tube (choice B) does not address the issue of maintaining sterility or preventing air leaks. Calling the physician (choice D) is not the immediate action needed to address the disconnection and potential contamination of the chest tube system.
Question 5 of 5
A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
Correct Answer: D
Rationale: The correct answer is D, Ineffective peripheral tissue perfusion related to venous congestion. Priority should be given to this nursing diagnosis because deep vein thrombosis can lead to impaired blood flow, potentially causing tissue ischemia and necrosis. Addressing ineffective tissue perfusion is crucial to prevent further complications such as tissue damage or even loss. Option A is incorrect as gas exchange is not the immediate concern in deep vein thrombosis. Option B is not directly related to the primary issue of venous congestion. Option C, risk for injury related to edema, is important but not as critical as ensuring adequate tissue perfusion to prevent further complications.