ATI RN
Introduction to Professional Nursing Questions
Question 1 of 5
What should the nurse do if a client with urinary incontinence has a urine output of 60ml over 3 hours?
Correct Answer: D
Rationale: The correct answer is D because palpating the patient's hypogastrium can help assess for bladder distension, which could be causing the urinary incontinence. By palpating the hypogastrium, the nurse can determine if the bladder is full and if the patient needs to void. This action is more appropriate than the other choices because stimulating the patient to urinate (choice A) may not address the underlying cause, informing the head nurse (choice B) is not an immediate action for this situation, and positioning the patient on his left side (choice C) is not directly related to assessing bladder distention.
Question 2 of 5
When assessing Frank for chest percussion or chest vibration and postural drainage, Mario would focus on the following, EXCEPT:
Correct Answer: C
Rationale: The correct answer is C because when assessing for chest percussion or chest vibration and postural drainage, Mario should focus on the client's respiratory status, not breath sounds and location of congestion. Breath sounds and congestion assessment are important for lung auscultation, not for the actual treatment techniques. A: Monitoring food and fluid intake is important to prevent aspiration during treatment. B: Respiratory rate indicates the client's respiratory effort and response to treatment. D: Teaching relatives to perform the procedure ensures continuity of care and client support. Therefore, C is the correct answer as it is not directly related to the assessment for these specific treatments.
Question 3 of 5
A nurse is caring for a client with a chest tube attached to a Pleurevac drainage system. Which of the following actions should the nurse avoid to prevent a tension pneumothorax?
Correct Answer: A
Rationale: Correct Answer: A: Clamping the chest tube Rationale: Clamping the chest tube can lead to a tension pneumothorax by preventing air from escaping the pleural space. This can cause a buildup of pressure, leading to lung collapse and potential life-threatening complications. Summary of other choices: B: Taping the connection can prevent air leaks and maintain the system's integrity. C: Adding water to the suction chamber is necessary to maintain suction and prevent air leaks. D: Maintaining the collection chamber below the client's waist helps with proper drainage and prevents backflow of fluid.
Question 4 of 5
A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?
Correct Answer: D
Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation is the final step where the nurse determines if the goals and outcomes of care have been achieved. In this scenario, the nurse is assessing the client's condition before discharge to ensure there are no signs of thrombophlebitis. The absence of pain, redness, and edema indicates successful treatment. This step aligns with the evaluation phase as the nurse is assessing the client's response to treatment. A: Assessment is incorrect because the nurse has already assessed the client's leg and is now determining the effectiveness of the treatment. B: Analysis is incorrect as this step involves interpreting the data collected during assessment to identify problems and make nursing diagnoses. C: Implementation is incorrect as this step involves carrying out the nursing interventions to achieve the established goals. The nurse has already implemented the treatment plan in this scenario.
Question 5 of 5
A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing?
Correct Answer: B
Rationale: The correct answer is B: Assessment. In this scenario, the nurse is collecting data by obtaining the health history, measuring vital signs, and auscultating for bowel sounds. Assessment is the first step in the nursing process, where data is gathered to identify the client's health status. Planning (A) involves setting goals and outcomes, Evaluation (C) involves determining the effectiveness of interventions, and Implementation (D) involves carrying out the planned interventions. In this case, the nurse is still in the data collection phase, making Assessment the correct choice.