ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. The client remaining free of signs and symptoms of phlebitis indicates that the I.V. site is not infected or inflamed, ensuring proper infusion. 2. Phlebitis can lead to complications such as infection and thrombosis if not managed promptly. 3. Monitoring for phlebitis is crucial to prevent further complications and ensure the client's safety. 4. Options A, C, and D do not directly address the expected outcome of maintaining the client free of phlebitis symptoms.
Question 5 of 5
When percussing a client's chest, the nurse should identify which sound as a normal finding?
Correct Answer: C
Rationale: The correct answer is C: Resonance. When percussing the chest, resonance is the normal sound produced over healthy lung tissue. It indicates air-filled lungs. Hyperresonance (A) is an abnormal sound found in conditions like emphysema. Tympany (B) is a drum-like sound heard over air-filled areas like the stomach. Dullness (D) is heard over solid organs or areas with fluid accumulation, indicating abnormal findings. In summary, resonance is the expected sound over healthy lung tissue, making it the correct choice.