ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
What should the nurse do when a client has a retention catheter?
Correct Answer: A
Rationale: The correct answer is A because cleaning the urinary meatus and adjacent skin periodically helps prevent infection and irritation. It maintains hygiene and reduces the risk of complications. Choice B is incorrect because fluid intake should be appropriate, not excessive. Choice C is incorrect because flushing the catheter without proper indication can introduce infection. Choice D is incorrect as perineal flushing is not recommended for clients with a retention catheter.
Question 2 of 5
Why is air drawn into the syringe for a Z-track injection?
Correct Answer: B
Rationale: The correct answer is B because adding air into the syringe creates a barrier that prevents the drug from flowing back into the needle track after injection, ensuring that the medication stays in the intended tissue site. This technique helps minimize tissue irritation and potential leakage of the medication. The other choices are incorrect because: A) Adding air does not decrease pain; C) The Z-track technique itself ensures the solution stays in the muscle, not air; D) Adding air does not ensure the client receives the entire dose, as the focus is on preventing backflow of the drug.
Question 3 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 4 of 5
Raymond is a 5-year-old with chronic disease. He had just undergone insertion of central venous catheter via ultrasound. Which of the assessment data should you look first prior to administration of IV fluids?
Correct Answer: D
Rationale: The correct answer is D: Chest radiology results. This is the most critical assessment data to look at first before administering IV fluids to Raymond. By checking the chest radiology results, we can ensure that the central venous catheter is properly placed without any complications such as pneumothorax or malposition. This step is crucial for safe IV fluid administration. A: Serum osmolality and B: Serum electrolyte levels are important assessments but are not as immediate as checking the catheter placement. C: Intake and output record is important for monitoring fluid balance but does not take precedence over confirming the catheter placement.
Question 5 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.