ATI RN
Introduction to Nursing Chapter 1 Quizlet Questions
Question 1 of 5
When assessing a child who complains of abdominal pain, what is the most appropriate nursing action?
Correct Answer: C
Rationale: The most appropriate nursing action when assessing a child complaining of abdominal pain is to avoid painful areas until the end of the assessment (Choice C). This approach helps prevent causing unnecessary discomfort or distress to the child. By starting with non-painful areas, the nurse can establish rapport, gather important information, and assess the child's overall condition before addressing the painful areas. This ensures a thorough and sensitive assessment process. Choice A is incorrect because palpating the most painful area first can cause distress and may not provide a comprehensive assessment. Choice B, palpating for rebound tenderness, is not appropriate as it is more specific to assessing for peritonitis in adults. Choice D, using deep palpation for abdominal tenderness, can be uncomfortable for the child and should be avoided until other assessments have been completed.
Question 2 of 5
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
Correct Answer: C
Rationale: The correct answer is C: Oral temperature of 101° F (38.3° C). A postoperative fever could indicate infection, especially in a diabetic patient who is at higher risk. The nurse should report this finding promptly for further evaluation and treatment. Choice A is within the normal range for blood glucose in a patient with diabetes. Choice B, separation of wound edges, could indicate delayed wound healing but is not as urgent as a potential infection. Choice D, increased incisional pain, is expected postoperatively and may not necessarily indicate a complication unless accompanied by other symptoms.
Question 3 of 5
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 6 breaths/min indicates severe respiratory distress, potentially leading to respiratory failure or arrest. This client needs immediate assessment and intervention to prevent further complications. A: A blood pressure of 100/50 mm Hg is low but not immediately life-threatening. B: A pulse of 118 beats/min is elevated but not as urgent as severe respiratory distress. D: A temperature of 96° F (35.6° C) is slightly below normal but not a priority compared to respiratory distress.
Question 4 of 5
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?
Correct Answer: A
Rationale: The correct answer is A: Airway. Priority in postoperative assessment is airway patency to ensure oxygenation and prevent airway obstruction. The rationale is based on the ABCs (Airway, Breathing, Circulation) of prioritizing patient care. Ensuring a clear airway is essential for adequate oxygenation and ventilation, preventing hypoxia and respiratory distress. Bleeding (B) can be addressed once airway is secured. Breathing (C) is important but comes after ensuring the airway. Cardiac rhythm (D) is important but is secondary to airway assessment in this situation.
Question 5 of 5
When assessing a patient who is receiving a loop diuretic, the nurse looks for the manifestations of potassium deficiency, which would include what symptoms? (Select the one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Loop diuretics can lead to potassium deficiency, which can manifest as symptoms such as muscle weakness, constipation, and tinnitus. Dyspnea is not typically associated with potassium deficiency. Potassium plays a crucial role in muscle and nerve function, so muscle weakness is a common symptom. Constipation can occur due to altered smooth muscle function with low potassium levels. Tinnitus can be a result of inner ear disturbances related to potassium imbalances. However, dyspnea is more commonly associated with respiratory or cardiovascular issues rather than potassium deficiency.