ATI RN
Introduction to Nursing Pdf Questions
Question 1 of 5
What should the nurse check first before giving oral care to a comatose client?
Correct Answer: C
Rationale: The correct answer is C: Gag reflex. This is crucial to prevent aspiration during oral care for a comatose client. Checking the gag reflex helps ensure that the client can protect their airway and swallow safely. It is the top priority before providing any oral care to prevent potential choking or aspiration. The other choices are incorrect because: A: Presence of pain is important, but ensuring the client's safety and preventing aspiration takes precedence. B: Condition of the integumentary is not directly related to oral care and safety during the procedure. D: Joint mobility is also not directly related to oral care in a comatose client.
Question 2 of 5
Nurse Mario knows he can perform chest physiotherapy:
Correct Answer: B
Rationale: Answer B is correct because performing chest physiotherapy one hour after meals helps prevent aspiration during the procedure. After meals, the risk of regurgitation and aspiration is higher, so waiting one hour allows for digestion and reduces these risks. Choices A, C, and D are incorrect because performing chest physiotherapy immediately before meals, during meals, or before bedtime can increase the risk of aspiration due to the timing in relation to eating.
Question 3 of 5
The nurse selects which of the following materials to be used as the first layer of the dressing at the chest tube insertion site?
Correct Answer: C
Rationale: The correct answer is C: Petrolatum jelly gauze. This material helps create a seal around the chest tube insertion site to prevent air leaks and infections. Step-by-step rationale: 1. Petrolatum jelly gauze provides an occlusive barrier to protect the site. 2. It helps maintain a moist environment for wound healing. 3. It reduces the risk of skin irritation. Summary: A dry sterile gauze (choice A) does not provide a proper seal or moisture needed for healing. Absorbent kelix dressing (choice B) may not create a sufficient barrier. Gauze with betadine (choice D) can be irritating and delay wound healing.
Question 4 of 5
A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask:
Correct Answer: B
Rationale: Step 1: Asking the client to describe the pain allows for a detailed account, aiding in identifying the cause. Step 2: Descriptions like sharp, dull, stabbing, or burning help determine the nature of the pain. Step 3: Location (choice C) and timing (choice A) are important but secondary to understanding the quality of pain. Step 4: Describing pain as stabbing (choice D) limits the client's response to a specific characteristic. Summary: Choice B is correct as it elicits comprehensive information about the pain quality, while the other choices focus on specific aspects that may not provide as much insight.
Question 5 of 5
The nurse is planning care for a client with type I insulin dependent diabetes mellitus (IDDM). Which statement best reflects a short-term goals for this client?
Correct Answer: D
Rationale: The correct answer is D because identifying elements of the basic diabetic diet is a short-term goal that is specific, measurable, achievable, relevant, and time-bound (SMART). This goal directly addresses the immediate need to manage blood glucose levels through proper nutrition. By the end of the week, the client should be able to apply this knowledge to their daily routine. A: While coping with anxiety is important, it is not directly related to the short-term management of diabetes. B: Understanding how to prevent complications is essential but may be a more long-term goal. C: Teaching about signs and symptoms of hypoglycemia and hyperglycemia is crucial, but it is more of an immediate educational need rather than a goal for the client to achieve.