ATI RN
Introduction to Nursing Pdf Questions
Question 1 of 5
What is the priority of care after the urinary catheter is removed?
Correct Answer: C
Rationale: The correct answer is C because after urinary catheter removal, priority is to evaluate the client for normal voiding to ensure proper bladder function. Encouraging fluid intake (A) is important for hydration. Documenting catheter size and client tolerance (B) is relevant but not a priority post-catheter removal. Documenting client teaching (D) is important but not the immediate priority.
Question 2 of 5
When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing?
Correct Answer: B
Rationale: The correct answer is B because oral hypoglycemic agents are important in managing blood sugar levels. High blood sugar can impair wound healing and increase the risk of infection. Controlling blood sugar levels is crucial for optimal wound healing. A: The duration of injury does not directly impact wound healing compared to managing underlying conditions. C: Pain management is important but does not directly affect wound healing. D: Keloids are unrelated to pressure injuries and do not impact wound healing.
Question 3 of 5
The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?
Correct Answer: A
Rationale: The correct answer is A: Administer high-ceiling (loop) diuretics. In fluid overload, loop diuretics help the body eliminate excess fluid rapidly, which is a priority intervention. Assessing lung sounds (B) is important but not as urgent as addressing the fluid overload. Placing a pressure-relieving overlay (C) is not directly related to managing fluid overload. Weighing the client daily (D) is important for monitoring fluid status but does not address the immediate need for fluid removal.
Question 4 of 5
A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?
Correct Answer: C
Rationale: The correct answer is C, the 76-year-old who is cognitively impaired, is at the greatest risk for dehydration. Cognitive impairment can impact one's ability to recognize thirst cues or communicate their need for fluids. This client may forget to drink water or be unable to express their thirst, leading to dehydration. The other choices are less likely at risk for dehydration because: A) Long-term steroid therapy can increase thirst and fluid intake, B) Recent IV fluids indicate recent hydration, D) Congestive heart failure may lead to fluid retention rather than dehydration.
Question 5 of 5
A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy?
Correct Answer: D
Rationale: The correct answer is D: Internal and superficial bleeding. Thrombolytic therapy works by breaking down blood clots, which can lead to bleeding as a side effect. This is the most common undesirable effect because it is directly related to the mechanism of action of thrombolytic agents. Dysrhythmias (choice A), although possible, are less common and not directly related to the drug's action. Nausea and vomiting (choice B) are general side effects that are not specific to thrombolytic therapy. Anaphylactic reactions (choice C) are rare but serious adverse effects that can occur with any medication, not just thrombolytics.