ATI RN
Falls Introduction to Nursing Quizlet Questions
Question 1 of 5
What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
Correct Answer: B
Rationale: The correct answer is B because oozing liquid stool is a common sign of fecal impaction in a paralyzed client. Due to decreased muscle tone and mobility, the client may have difficulty passing formed stool, leading to leakage of liquid stool around the impaction. Presence of blood in stools (A) may indicate other gastrointestinal issues. Continuous flatulence (C) is common with impaction but not specific. Absence of bowel movements (D) can be a sign of impaction but is not as reliable as oozing liquid stool.
Question 2 of 5
When suctioning, which of the following techniques is correct?
Correct Answer: C
Rationale: The correct technique for suctioning is using intermittent suction while withdrawing the catheter (Choice C) because it helps prevent injury to the airway and reduce the risk of hypoxia. Intermittent suctioning allows for effective removal of secretions without causing trauma to the airway tissues. Advancing the catheter while suctioning can stimulate the gag reflex and cause injury, while continuous suctioning can lead to hypoxia and damage to the airway mucosa. Therefore, using intermittent suction while withdrawing the catheter ensures safe and effective suctioning without compromising patient safety.
Question 3 of 5
After circulation has ceased, discoloration appears in the lowermost or dependent areas of the body of the deceased. This is known as:
Correct Answer: C
Rationale: The correct answer is C: Livor mortis. Livor mortis is the pooling of blood in the lowermost areas of the body post-mortem due to gravity. This occurs after circulation stops, causing discoloration in dependent areas. Algor mortis (choice A) refers to the cooling of the body after death, Rigor mortis (choice B) is the stiffening of muscles post-mortem, and Manor mortis (choice D) is not a recognized term in forensic science.
Question 4 of 5
The nurse is preparing to administer a blood transfusion. Which action should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B. Comparing the client's identification wristband with the tag on the unit of blood is crucial to ensure proper patient identification and prevent errors in blood transfusion. This step helps verify patient identity and blood compatibility before administration. Incorrect Choices: A: Typing and crossmatching can be done after patient identification to confirm compatibility. C: Starting an IV infusion of normal saline is important but not the first step in blood transfusion. D: Measuring vital signs is important but should not be the first action before verifying patient identity for blood transfusion.
Question 5 of 5
In changing tracheostomy ties, the nurse should:
Correct Answer: C
Rationale: Rationale: Choice C is correct because it involves removing one side of the old tie before threading the clean tape through the eye of the flange. This method ensures that the tracheostomy remains secure while changing ties, reducing the risk of accidental decannulation or displacement. Removing both ties (Choice D) can compromise the patient's airway, while tying the new tie to the eye of the flange with old ties in place (Choice B) can lead to inadequate support. Choice A is incorrect because threading the clean tape through the eye of the flange before removing the old ties can result in instability and potential harm to the patient.