ATI RN
Introduction to Nursing 203 Quizlet Questions
Question 1 of 5
When assessing a client's skin, the nurse notes a deep, irregular-shaped area of skin loss that extends below the dermis. What term would the nurse use when documenting this?
Correct Answer: A
Rationale: The correct term for a deep, irregular-shaped area of skin loss that extends below the dermis is an ulcer. Ulcers are characterized by tissue loss extending beyond the epidermis and dermis. A fissure is a linear crack in the skin, not a deep irregular shape. Keloid is an overgrowth of scar tissue, not skin loss. Erosion is superficial loss of the epidermis, not extending below the dermis. Therefore, the correct term in this scenario would be an ulcer.
Question 2 of 5
The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
Correct Answer: C
Rationale: The correct answer is C: Reposition every 2 hours. Repositioning every 2 hours helps to relieve pressure on bony prominences, reducing the risk of skin breakdown. This measure promotes circulation and tissue oxygenation. A: Placing the client in a wheelchair for extended periods can increase pressure on bony areas, leading to skin breakdown. B: Padding bony prominences may provide some protection but does not address the root cause of pressure. D: Massaging reddened areas can cause further damage to fragile skin and should be avoided.
Question 3 of 5
The client has developed liver failure. Which of the following laboratory values would Nurse Irene expect to have alterations?
Correct Answer: B
Rationale: The correct answer is B: Clotting factors. Liver failure can lead to impaired synthesis of clotting factors, resulting in abnormal coagulation tests. A: Blood urea nitrogen and creatinine are more related to kidney function. C: Creatinine kinase is an enzyme related to muscle breakdown. D: C-reactive protein is a marker of inflammation and infection, not specific to liver function. In liver failure, alterations in clotting factors are commonly seen due to the liver's role in synthesizing these proteins.
Question 4 of 5
You are to insert an indwelling catheter for a female client, after the insertion of the catheter still the urine does not flow. You made a conclusion that you might have inserted the catheter into the vagina. In response to this, you should:
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Leave the catheter in place and insert another one): If urine does not flow after catheter insertion, it indicates the catheter may be in the vagina. Leaving the catheter in place prevents further complications. Inserting another catheter correctly ensures urine drainage. Removing the catheter and reinserting it (choice A) risks causing trauma. Irrigating the catheter with saline (choice B) is unnecessary and may worsen the situation. Inserting the catheter further (choice D) can cause harm.
Question 5 of 5
The minimum time in washing each hand should never be below:
Correct Answer: C
Rationale: The correct answer is C (15 seconds) as recommended by health authorities. Washing hands thoroughly for at least 15 seconds ensures proper removal of dirt, germs, and viruses. This duration allows for adequate friction and coverage of all areas of the hands, including between fingers and under nails. Option A (5 seconds) is too short and insufficient for effective cleaning. Option B (10 seconds) may not provide thorough cleaning, especially in challenging situations. Option D (30 seconds) is longer than necessary and may not offer additional benefits compared to 15 seconds. Therefore, option C is the most appropriate choice for proper hand hygiene.