ATI RN
Introduction to Nursing Chapter 1 Quizlet Questions
Question 1 of 5
What should a client discharged with Coumadin (warfarin) be instructed to do?
Correct Answer: B
Rationale: Correct Answer: B - Avoid green leafy vegetables. Rationale: 1. Coumadin is a blood thinner that works by affecting vitamin K levels. 2. Green leafy vegetables are high in vitamin K, which can interfere with Coumadin's effectiveness. 3. Instructing the client to avoid green leafy vegetables helps maintain a consistent level of vitamin K in the diet, thus ensuring the proper effect of Coumadin. Summary of other choices: A: Having a PTT done monthly is not necessary for a client discharged with Coumadin. C: Drinking more liquids is not directly related to Coumadin therapy. D: Avoiding crowds is unrelated to Coumadin therapy and does not impact its effectiveness.
Question 2 of 5
After the blood transfusion, you assessed the client for blood transfusion reactions. The following assessments were noted: HR: 120 bpm, Pulse: +4 in quality, presence of fine, short, high pitched crackling at base. Which of the following is your FIRST action?
Correct Answer: D
Rationale: The correct first action is D: Consult with the primary health care provider (PHCP) regarding initiation of oxygen therapy. This is because the client is showing signs of a potential transfusion reaction, likely a pulmonary embolism. The client's rapid heart rate, bounding pulse, and crackling sound at the base suggest a possible pulmonary issue. Oxygen therapy is crucial to improve oxygenation and stabilize the client's condition. Consulting with the PHCP ensures timely intervention and appropriate management. A: Maintaining bed rest with legs elevated would not address the potential respiratory distress the client is experiencing. B: Placing the client in high-Fowler's position may help improve oxygenation, but consulting the PHCP for oxygen therapy is the priority. C: Increasing the rate of IV fluids is not the priority when the client is showing signs of a potential serious complication like a pulmonary embolism.
Question 3 of 5
Mrs. David is obese. When administering a subcutaneous injection to an obese patient, it is best for Nurse Andrae to:
Correct Answer: D
Rationale: The correct answer is D. When administering a subcutaneous injection to an obese patient, it is best for Nurse Andrae to spread or pinch the skin at the injection site and inject the needle at a 45-90 degree angle. This allows for proper medication absorption due to the thicker layer of subcutaneous fat in obese patients. Pinching the skin helps ensure the medication is injected into the subcutaneous tissue rather than the muscle. Options A and B are not ideal for obese patients as they may not penetrate the thicker layer of fat effectively. Option C, the Z track method, is typically used for intramuscular injections and is not necessary for subcutaneous injections in obese patients.
Question 4 of 5
At 8:00 a.m., Nurse Corazon is preparing to change the Total Parenteral Nutrition (TPN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse would instruct the client to do which of the following during the tubing change?
Correct Answer: C
Rationale: The correct answer is C: Ask the client to take a deep breath, hold, and bear down during the tubing change. This action helps to prevent air embolism by increasing intrathoracic pressure, which reduces the risk of air being drawn into the central venous line. When the client bears down, the pressure in the thorax increases, preventing air from being sucked into the vein. Choices A, B, and D are incorrect because they do not address the specific action needed to prevent air embolism during the tubing change. Breathing normally (choice A) or turning the head to the right (choice B) will not help in preventing air embolism. Exhaling slowly and evenly (choice D) does not provide the necessary increase in intrathoracic pressure to prevent air entry into the central venous line.
Question 5 of 5
A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client?
Correct Answer: C
Rationale: The correct answer is C: Deficient fluid volume related to nausea and vomiting. Priority is given to addressing fluid volume deficits to prevent dehydration and electrolyte imbalances. Nausea, vomiting, and fever can lead to significant fluid loss. Choice A is incorrect as excessive fluid volume is not indicated. Choice B is incorrect as addressing nutrition would come after addressing fluid volume. Choice D is incorrect as hyperventilation does not typically lead to ineffective cardiopulmonary tissue perfusion in this scenario.